Provider Demographics
NPI:1932727476
Name:MANSOUR, PHILIPPE (DMD)
Entity Type:Individual
Prefix:DR
First Name:PHILIPPE
Middle Name:
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1341 DUKES CREEK DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-8232
Mailing Address - Country:US
Mailing Address - Phone:404-769-0216
Mailing Address - Fax:
Practice Address - Street 1:3740 SOUTH 14TH ST
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS-MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98433
Practice Address - Country:US
Practice Address - Phone:253-967-5271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN016045122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist