Provider Demographics
NPI:1053489807
Name:MANSOUR, NIZAR NAUM (DDS MS)
Entity Type:Individual
Prefix:MR
First Name:NIZAR
Middle Name:NAUM
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28437 GREENFIELD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076
Mailing Address - Country:US
Mailing Address - Phone:248-557-5461
Mailing Address - Fax:248-559-3163
Practice Address - Street 1:28437 GREENFIELD RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076
Practice Address - Country:US
Practice Address - Phone:248-557-5461
Practice Address - Fax:248-559-3163
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901012608122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4074460Medicaid
12608OtherBLUE CROSS
MI4065433Medicaid