Provider Demographics
NPI:1528399888
Name:MANSOOR, CHARLES A
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:MANSOOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 E 64TH ST APT 302
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-7461
Mailing Address - Country:US
Mailing Address - Phone:646-338-2345
Mailing Address - Fax:
Practice Address - Street 1:125 E 64TH ST OFC 1
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-7041
Practice Address - Country:US
Practice Address - Phone:646-338-2345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-26
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0414701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice