Provider Demographics
NPI:1679906895
Name:AAVA DENTAL OF FOOTHILL RANCH A MANSOUR DENTAL GROUP INC RODEO MANAGEM
Entity Type:Organization
Organization Name:AAVA DENTAL OF FOOTHILL RANCH A MANSOUR DENTAL GROUP INC RODEO MANAGEM
Other - Org Name:AAVA DENTAL OF FOOTHILL RANCH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YAHYA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-529-8151
Mailing Address - Street 1:27462 PORTOLA PKWY
Mailing Address - Street 2:STE 205
Mailing Address - City:FOOTHILL RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92610-2838
Mailing Address - Country:US
Mailing Address - Phone:817-529-8151
Mailing Address - Fax:817-529-8156
Practice Address - Street 1:27462 PORTOLA PKWY
Practice Address - Street 2:STE 205
Practice Address - City:FOOTHILL RANCH
Practice Address - State:CA
Practice Address - Zip Code:92610-2838
Practice Address - Country:US
Practice Address - Phone:817-529-8151
Practice Address - Fax:817-529-8156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-12
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58012122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty