Provider Demographics
NPI:1821288226
Name:MANSOURI, AZITA AGHARAHIMI (DMD)
Entity Type:Individual
Prefix:DR
First Name:AZITA
Middle Name:AGHARAHIMI
Last Name:MANSOURI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 LAWRENCEVILLE HWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-4411
Mailing Address - Country:US
Mailing Address - Phone:770-962-1977
Mailing Address - Fax:770-962-9886
Practice Address - Street 1:2401 LAWRENCEVILLE HWY
Practice Address - Street 2:SUITE A
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-4411
Practice Address - Country:US
Practice Address - Phone:770-962-1977
Practice Address - Fax:770-962-9886
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013537122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist