Provider Demographics
NPI:1568646628
Name:MADANI, MANSOOR (DMD)
Entity Type:Individual
Prefix:DR
First Name:MANSOOR
Middle Name:
Last Name:MADANI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 PRESIDENTIAL BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1006
Mailing Address - Country:US
Mailing Address - Phone:610-667-4455
Mailing Address - Fax:
Practice Address - Street 1:15 N PRESIDENTIAL BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1006
Practice Address - Country:US
Practice Address - Phone:610-667-4455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-26
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS023126L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1610569OtherUNITED CONCORDIA
PA1610569OtherHIGHMARK
PA172847OtherBLUE SHIELD
PAMA172847OtherHIGHMARK
PA4517236OtherAETNA