Provider Demographics
NPI:1417161936
Name:ALEMANSOUR, SIAMAK (DDS)
Entity Type:Individual
Prefix:
First Name:SIAMAK
Middle Name:
Last Name:ALEMANSOUR
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 1:9045 HOLLY LEAF LN
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-2657
Mailing Address - Country:US
Mailing Address - Phone:410-535-5055
Mailing Address - Fax:
Practice Address - Street 1:230 W DARES BEACH RD
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-3150
Practice Address - Country:US
Practice Address - Phone:410-535-5055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD126301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice