Basic Information
| Provider Information | |||||||||
| NPI: | 1609302207 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANSKI | ||||||||
| FirstName: | ALYSSA | ||||||||
| MiddleName: | GAIL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FLASHBURG | ||||||||
| OtherFirstName: | ALYSSA | ||||||||
| OtherMiddleName: | GAIL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD, DDS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 909 WALNUT ST | ||||||||
| Address2: | ROOM 300 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155037118 | ||||||||
| FaxNumber: | 2159239189 | ||||||||
| Practice Location | |||||||||
| Address1: | 909 WALNUT ST | ||||||||
| Address2: | ROOM 300 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155036215 | ||||||||
| FaxNumber: | 2159239189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2017 | ||||||||
| LastUpdateDate: | 07/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1223S0112X | DS041375 | PA | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.