Provider Demographics
NPI:1043316698
Name:MANCUSO, MARY T (DMD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 GLENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NORTH HALEDON
Mailing Address - State:NJ
Mailing Address - Zip Code:07508-3020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27-11 PELLACK DR
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3723
Practice Address - Country:US
Practice Address - Phone:201-796-7171
Practice Address - Fax:201-796-0600
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ178351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice