Provider Demographics
NPI:1356819122
Name:MANCUSO DENTAL LLC
Entity Type:Organization
Organization Name:MANCUSO DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MANCUSO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-397-7799
Mailing Address - Street 1:7337 FARNAM ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-4627
Mailing Address - Country:US
Mailing Address - Phone:402-397-7799
Mailing Address - Fax:402-939-0330
Practice Address - Street 1:7337 FARNAM ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4627
Practice Address - Country:US
Practice Address - Phone:402-397-7799
Practice Address - Fax:402-939-0330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-09
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty