Provider Demographics
NPI:1508967704
Name:MANCUSO, VICTOR R (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:R
Last Name:MANCUSO
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 SE LAKE RD STE 140
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2194
Mailing Address - Country:US
Mailing Address - Phone:503-496-4766
Mailing Address - Fax:503-496-4700
Practice Address - Street 1:6400 SE LAKE RD STE 140
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97222-2194
Practice Address - Country:US
Practice Address - Phone:503-496-4766
Practice Address - Fax:503-496-4700
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA376981223E0200X
ORD104051223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics