Provider Demographics
NPI:1164207981
Name:MANSOURI, NIKTA
Entity Type:Individual
Prefix:
First Name:NIKTA
Middle Name:
Last Name:MANSOURI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 DEERGLEN TERRACE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:ON
Mailing Address - Zip Code:L4G 6Y4
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2370 FAIRVIEW AVE N
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4467
Practice Address - Country:US
Practice Address - Phone:651-365-2848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14993122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist