Provider Demographics
NPI:1568679918
Name:MANSOURI, SHIDEH (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHIDEH
Middle Name:
Last Name:MANSOURI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10595 ASHTON AVE
Mailing Address - Street 2:#102
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024
Mailing Address - Country:US
Mailing Address - Phone:310-283-2273
Mailing Address - Fax:
Practice Address - Street 1:9722 LAUREL CANYON BLVD
Practice Address - Street 2:
Practice Address - City:ARLETA
Practice Address - State:CA
Practice Address - Zip Code:91331-4106
Practice Address - Country:US
Practice Address - Phone:818-897-1234
Practice Address - Fax:818-834-1064
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45389122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist