MEDICARE: DR. TYRA MANSO DDS

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	1223P0221X	Pediatric Dentistry	22DI023814	NJ
2	1223P0221X	Pediatric Dentistry	0539911	NY

General Provider Information

NPI Number	:	1467618512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TYRA MANSO DDS

Provider Business Mailing Address
First Line	:	31 VALLEY RD
Second Line	:	2ND FLOOR
City	:	MONTCLAIR
State	:	NJ
Zip	:	07042-2708
Country	:	US
Telephone Number	:	973-771-5387
Fax Number	:

Provider Business Practice Location Address
First Line	:	31 VALLEY RD
Second Line	:	2ND FLOOR
City	:	MONTCLAIR
State	:	NJ
Zip	:	07042-2708
Country	:	US
Telephone Number	:	973-771-5387
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2008
Last Update Date	:	06/02/2016

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