Provider Demographics
NPI:1851501134
Name:MARIE MANSOUR DMD, MS DENTAL CORP
Entity Type:Organization
Organization Name:MARIE MANSOUR DMD, MS DENTAL CORP
Other - Org Name:CENTRAL ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:CLAIRE
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:818-500-7030
Mailing Address - Street 1:709 S. CENTRAL AVE #B
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204
Mailing Address - Country:US
Mailing Address - Phone:818-500-7030
Mailing Address - Fax:818-500-7040
Practice Address - Street 1:709 S CENTRAL AVE # B
Practice Address - Street 2:SUITE B
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2010
Practice Address - Country:US
Practice Address - Phone:818-500-7030
Practice Address - Fax:818-500-7040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA512831223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty