Provider Demographics
NPI:1821289687
Name:MANSOURI, FAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:FAY
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 1:2500 ALTON PKWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-5024
Mailing Address - Country:US
Mailing Address - Phone:949-622-0055
Mailing Address - Fax:949-681-8407
Practice Address - Street 1:2500 ALTON PKWY
Practice Address - Street 2:SUITE 202
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606-5024
Practice Address - Country:US
Practice Address - Phone:949-622-0055
Practice Address - Fax:949-681-8407
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47164122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist