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General NPI Number Information
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NPI Number | 1124236674
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Entity Type | Individual
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Provider Name | MATTHEW DAVID MANCUSO D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 05/18/2007
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Last Update Date | 08/23/2016
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Provider Practice Location Address
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Address Line | 1800 W CHESTNUT ST SUITE 154
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City | DENTON
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State | TX
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Zip | 76201
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Country | US
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Telephone | 940-273-2184
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Fax |
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Provider Business Mailing Address
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Address Line | 34 CREEKSIDE DR
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City | TROPHY CLUB
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State | TX
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Zip | 76262-5246
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 049594
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 30578
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License Number State | TX
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