Provider Demographics
NPI:1164001509
Name:MANCUSO, RYAN (DDS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MANCUSO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 COUNTY ROAD 28 UNIT K3
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-8185
Mailing Address - Country:US
Mailing Address - Phone:716-581-2963
Mailing Address - Fax:
Practice Address - Street 1:329 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-2118
Practice Address - Country:US
Practice Address - Phone:854-716-7845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2022-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062418122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist