Provider Demographics
NPI:1760712236
Name:MANASSE, MARYSE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARYSE
Middle Name:
Last Name:MANASSE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2724
Mailing Address - Country:US
Mailing Address - Phone:973-743-4743
Mailing Address - Fax:973-743-4780
Practice Address - Street 1:275 BROAD ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-2724
Practice Address - Country:US
Practice Address - Phone:973-743-4743
Practice Address - Fax:973-743-4780
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02318200122300000X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist