Provider Demographics
NPI:1194862896
Name:MANSOURI, MICHAEL S (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:MANSOURI
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 1:2401 LAWRENCEVILLE HWY STE A
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-4411
Mailing Address - Country:US
Mailing Address - Phone:770-962-0014
Mailing Address - Fax:770-962-9886
Practice Address - Street 1:2401 LAWRENCEVILLE HWY STE A
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-4411
Practice Address - Country:US
Practice Address - Phone:770-962-0014
Practice Address - Fax:770-962-9886
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012848122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist