Provider Demographics
NPI:1134227796
Name:MANSOUR, MARIE CLAIRE (DMD, MS)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:CLAIRE
Last Name:MANSOUR
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 CLINTON PL
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-1917
Mailing Address - Country:US
Mailing Address - Phone:310-497-7881
Mailing Address - Fax:310-858-8333
Practice Address - Street 1:709 S CENTRAL AVE
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
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA512831223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics