Provider Demographics
NPI:1376220517
Name:MANSOURI, CYRUS JON (DDS)
Entity Type:Individual
Prefix:DR
First Name:CYRUS
Middle Name:JON
Last Name:MANSOURI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6377 CANAL BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70124-3117
Mailing Address - Country:US
Mailing Address - Phone:224-456-9191
Mailing Address - Fax:
Practice Address - Street 1:1100 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-2715
Practice Address - Country:US
Practice Address - Phone:504-619-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-29
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7473122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program