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General NPI Number Information
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NPI Number | 1790746048
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Entity Type | Individual
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Provider Name | VINCENT W MANCUSO JR. DDS
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Gender | Male
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Dates
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Enumeration Date | 03/28/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1000 73RD ST SUITE 10
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City | WINDSOR HEIGHTS
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State | IA
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Zip | 50311-1321
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Country | US
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Telephone | 515-223-1298
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Fax | 515-223-1959
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Provider Business Mailing Address
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Address Line | 1000 73RD ST SUITE 10
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City | WINDSOR HEIGHTS
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State | IA
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Zip | 50311-1321
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Country | US
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Telephone | 515-223-1298
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Fax | 515-223-1959
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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 | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 5809
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License Number State | IA
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