Provider Demographics
NPI:1245598770
Name:MANSOUR, MOHAMED M (DDS,MSD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:M
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:DDS,MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 MLK JR BLVD
Mailing Address - Street 2:UNIVERSITY OF DETROIT MERCY ,SCHOOL OF DENTISTRY
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48208-2576
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2700 MLK JR BLVD
Practice Address - Street 2:UNIVERSITY OF DETROIT MERCY ,SCHOOL OF DENTISTRY
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-2576
Practice Address - Country:US
Practice Address - Phone:313-494-6669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-03
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020110122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist