MEDICARE: COMPREHENSIVE & COSMETIC & GENERAL DISTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	11320	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11320	OTHER	NJ	INS CO'S
2	90730-00-4	OTHER	NJ	NJ EMPLOYER ID

General Provider Information

NPI Number	:	1104930668
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMPREHENSIVE & COSMETIC & GENERAL DISTISTRY

Provider Business Mailing Address
First Line	:	3350 STATE ROUTE 138
Second Line	:	STE 127
City	:	WALL TOWNSHIP
State	:	NJ
Zip	:	07719-9693
Country	:	US
Telephone Number	:	732-556-9600
Fax Number	:	732-556-9601

Provider Business Practice Location Address
First Line	:	3350 STATE ROUTE 138
Second Line	:	STE 127
City	:	WALL TOWNSHIP
State	:	NJ
Zip	:	07719-9693
Country	:	US
Telephone Number	:	732-556-9600
Fax Number	:	732-556-9601

Authorized Official
Title or Position	:	OWNER,PRESIDENT
Name	:	ANTHONY JOSEPH MANCINO
Credential	:	DDS
Telephone Number	:	732-556-9600

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	05/06/2015

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Directions to “COMPREHENSIVE & COSMETIC & GENERAL DISTISTRY ” Practice Location

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