Provider Demographics
NPI:1609024975
Name:MANUSOV, MARINA (RDH)
Entity Type:Individual
Prefix:MRS
First Name:MARINA
Middle Name:
Last Name:MANUSOV
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7811 35TH AVE APT 5A
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-2539
Mailing Address - Country:US
Mailing Address - Phone:718-505-9644
Mailing Address - Fax:
Practice Address - Street 1:57 W 57TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-2802
Practice Address - Country:US
Practice Address - Phone:212-751-6428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023998-1124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist