Provider Demographics
NPI:1063828218
Name:MANZUR, KASIM (DMD)
Entity Type:Individual
Prefix:
First Name:KASIM
Middle Name:
Last Name:MANZUR
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 1:3590 BAYSIDE LAKES BLVD SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-6866
Mailing Address - Country:US
Mailing Address - Phone:321-984-0044
Mailing Address - Fax:
Practice Address - Street 1:3590 BAYSIDE LAKES BLVD SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-6866
Practice Address - Country:US
Practice Address - Phone:321-984-0044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20767122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist