MEDICARE: RICHARD MANCUSO DMD PLLC

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	122300000X	Dentist	DN20889	FL

General Provider Information

NPI Number	:	1720531528
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RICHARD MANCUSO DMD PLLC

Provider Business Mailing Address
First Line	:	222 NW 48TH AVE
Second Line	:
City	:	DEERFIELD BEACH
State	:	FL
Zip	:	33442-9308
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4536 W VILLAGE DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33624-3429
Country	:	US
Telephone Number	:	954-605-0865
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. RICHARD MANCUSO
Credential	:	D.M.D.
Telephone Number	:	954-605-0865

Provider Enumeration Date	:	07/27/2016
Last Update Date	:	07/27/2016

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