Provider Demographics
NPI:1306056973
Name:MANDOR, RUSS B (DDS)
Entity type:Individual
Prefix:DR
First Name:RUSS
Middle Name:B
Last Name:MANDOR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 E 72ND ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4245
Mailing Address - Country:US
Mailing Address - Phone:212-737-5068
Mailing Address - Fax:
Practice Address - Street 1:30 CENTRAL PARK SOUTH
Practice Address - Street 2:SUITE #7C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019
Practice Address - Country:US
Practice Address - Phone:212-755-3473
Practice Address - Fax:212-755-2055
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033128122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist