Provider Demographics
NPI:1124236674
Name:MANCUSO, MATTHEW DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DAVID
Last Name:MANCUSO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 CREEKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:TROPHY CLUB
Mailing Address - State:TX
Mailing Address - Zip Code:76262-5246
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 W CHESTNUT ST
Practice Address - Street 2:SUITE 154
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201
Practice Address - Country:US
Practice Address - Phone:940-273-2184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0495941223G0001X
TX305781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice