Healthcare Provider Details

I. General information

NPI: 1609024975
Provider Name (Legal Business Name): MARINA MANUSOV RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 08/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 W 57TH ST
NEW YORK NY
10019-2802
US

IV. Provider business mailing address

7811 35TH AVE APT 5A
JACKSON HEIGHTS NY
11372-2539
US

V. Phone/Fax

Practice location:
  • Phone: 212-751-6428
  • Fax:
Mailing address:
  • Phone: 718-505-9644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number023998-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: