MEDICARE: DR. RICHARD MANCUSO D.M.D.

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	1223G0001X	General Practice Dentistry	DN 20889	FL

General Provider Information

NPI Number	:	1861892242
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD MANCUSO D.M.D.

Provider Business Mailing Address
First Line	:	4536 W VILLAGE DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33624-3429
Country	:	US
Telephone Number	:	813-961-2200
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	:	813-961-2200
Fax Number	:

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

Provider Enumeration Date	:	09/04/2014
Last Update Date	:	10/24/2016

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