Provider Demographics
NPI:1679632467
Name:MOHEBAN, MANSOUR (DMD)
Entity Type:Individual
Prefix:DR
First Name:MANSOUR
Middle Name:
Last Name:MOHEBAN
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 1:154 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01532-1930
Mailing Address - Country:US
Mailing Address - Phone:508-393-2522
Mailing Address - Fax:508-393-9782
Practice Address - Street 1:154 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01532-1930
Practice Address - Country:US
Practice Address - Phone:508-393-2522
Practice Address - Fax:508-393-9782
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA119051223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics