Provider Demographics
NPI:1003535030
Name:MANCUSO, MARIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11714 SW WESTCLIFFE LN
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2106
Mailing Address - Country:US
Mailing Address - Phone:631-278-3397
Mailing Address - Fax:
Practice Address - Street 1:11714 SW WESTCLIFFE LN
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2106
Practice Address - Country:US
Practice Address - Phone:631-278-3397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017103-01124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist