Provider Demographics
NPI:1215552633
Name:AYUSO, SELENE (DMD)
Entity Type:Individual
Prefix:
First Name:SELENE
Middle Name:
Last Name:AYUSO
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 1:130 S STATE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:19064-1232
Mailing Address - Country:US
Mailing Address - Phone:617-997-3565
Mailing Address - Fax:
Practice Address - Street 1:130 S STATE RD STE 300
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064-1232
Practice Address - Country:US
Practice Address - Phone:610-622-1949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-11
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18586621223G0001X
PADS0430911223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice