Provider Demographics
NPI:1790860146
Name:MANSFIELD, MICHAEL JAMES (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
Last Name:MANSFIELD
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 1:6677 W THUNDERBIRD RD
Mailing Address - Street 2:STE H 120
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306
Mailing Address - Country:US
Mailing Address - Phone:623-792-5794
Mailing Address - Fax:623-792-5809
Practice Address - Street 1:6677 W THUNDERBIRD RD
Practice Address - Street 2:STE H 120
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306
Practice Address - Country:US
Practice Address - Phone:623-792-5794
Practice Address - Fax:623-792-5809
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD31781223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
U13388Medicare UPIN
DMD317891Medicare ID - Type Unspecified