Provider Demographics
NPI:1467833137
Name:MANCUSO, GABRIEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:
Last Name:MANCUSO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 N FRONT ST
Mailing Address - Street 2:
Mailing Address - City:PHILIPSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16866-1603
Mailing Address - Country:US
Mailing Address - Phone:814-342-1090
Mailing Address - Fax:814-343-2597
Practice Address - Street 1:101 N FRONT ST
Practice Address - Street 2:
Practice Address - City:PHILIPSBURG
Practice Address - State:PA
Practice Address - Zip Code:16866-1603
Practice Address - Country:US
Practice Address - Phone:814-342-1090
Practice Address - Fax:814-343-2597
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-17
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS040423122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist