Provider Demographics
NPI:1013005214
Name:MANSOUR, HAIFA (DDS, PC)
Entity Type:Individual
Prefix:DR
First Name:HAIFA
Middle Name:
Last Name:MANSOUR
Suffix:
Gender:F
Credentials:DDS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27753 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-3477
Mailing Address - Country:US
Mailing Address - Phone:248-582-8060
Mailing Address - Fax:248-582-8062
Practice Address - Street 1:27753 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-3477
Practice Address - Country:US
Practice Address - Phone:248-582-8060
Practice Address - Fax:248-582-8062
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010170251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4642511Medicaid
MI979396OtherUNITED CONCORDIA