=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467833137
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GABRIEL MANCUSO DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2015
-----------------------------------------------------
Last Update Date | 04/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 N FRONT ST
-----------------------------------------------------
City | PHILIPSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16866-1603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-342-1090
-----------------------------------------------------
Fax | 814-343-2597
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 N FRONT ST
-----------------------------------------------------
City | PHILIPSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16866-1603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-342-1090
-----------------------------------------------------
Fax | 814-343-2597
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS040423
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------