Provider Demographics
NPI:1871506360
Name:MANSOUR, ENGELLA SAMAR (DDS)
Entity Type:Individual
Prefix:
First Name:ENGELLA
Middle Name:SAMAR
Last Name:MANSOUR
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 1:1324 GARNET AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-3011
Mailing Address - Country:US
Mailing Address - Phone:619-275-2750
Mailing Address - Fax:619-275-1935
Practice Address - Street 1:1324 GARNET AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-3011
Practice Address - Country:US
Practice Address - Phone:619-275-2750
Practice Address - Fax:619-275-1935
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42615122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist