Provider Demographics
NPI:1225056971
Name:MANCUSO, VINCENT R (DDS)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:R
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 1:1730 WEST 25TH STREET
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-3108
Mailing Address - Country:US
Mailing Address - Phone:216-861-5330
Mailing Address - Fax:216-623-7596
Practice Address - Street 1:1730 WEST 25TH STREET
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-3108
Practice Address - Country:US
Practice Address - Phone:216-861-5330
Practice Address - Fax:216-623-7596
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0164511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0490142Medicaid