Provider Demographics
NPI:1649885492
Name:MANCUSO, VANESSA LYNN (DDS, MSD)
Entity type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:LYNN
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:DDS, MSD
Other - Prefix:DR
Other - First Name:VANESSA
Other - Middle Name:LYNN
Other - Last Name:MANCUSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1312 E BROWARD BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-2136
Mailing Address - Country:US
Mailing Address - Phone:786-449-4262
Mailing Address - Fax:
Practice Address - Street 1:1312 E BROWARD BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-2136
Practice Address - Country:US
Practice Address - Phone:786-449-4262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN254751223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics