Provider Demographics
NPI:1558524041
Name:MANSOUR, KELLY CONNAUGHTON (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:CONNAUGHTON
Last Name:MANSOUR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:LEE
Other - Last Name:CONNAUGHTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1650 N MAITLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-3320
Mailing Address - Country:US
Mailing Address - Phone:074-628-2286
Mailing Address - Fax:
Practice Address - Street 1:1650 N MAITLAND AVE
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-3320
Practice Address - Country:US
Practice Address - Phone:407-628-2286
Practice Address - Fax:407-629-2953
Is Sole Proprietor?:No
Enumeration Date:2008-07-06
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN183771223P0221X
FLDN 183771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice