Provider Demographics
NPI:1225096589
Name:MANCUSO, STPHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:STPHEN
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 1:7350 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:PIGEON
Mailing Address - State:MI
Mailing Address - Zip Code:48755-5149
Mailing Address - Country:US
Mailing Address - Phone:989-453-2256
Mailing Address - Fax:989-453-3270
Practice Address - Street 1:7350 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:PIGEON
Practice Address - State:MI
Practice Address - Zip Code:48755-5149
Practice Address - Country:US
Practice Address - Phone:989-453-2256
Practice Address - Fax:989-453-3270
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI013779122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist