Provider Demographics
NPI:1780920702
Name:DR. MANSOUR
Entity type:Organization
Organization Name:DR. MANSOUR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YAHYA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-529-8151
Mailing Address - Street 1:68487 E PALM CANYON DR STE 1
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CTY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-5434
Mailing Address - Country:US
Mailing Address - Phone:760-770-2776
Mailing Address - Fax:
Practice Address - Street 1:68487 E PALM CANYON DR STE 1
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CTY
Practice Address - State:CA
Practice Address - Zip Code:92234-5434
Practice Address - Country:US
Practice Address - Phone:760-770-2776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-19
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58012122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty