Provider Demographics
NPI:1952808297
Name:MANSOUR, SHADEE T (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHADEE
Middle Name:T
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 1:1113 LOUGHBOROUGH CT
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-7618
Mailing Address - Country:US
Mailing Address - Phone:630-815-8042
Mailing Address - Fax:
Practice Address - Street 1:203 W NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-3104
Practice Address - Country:US
Practice Address - Phone:847-381-6222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.025463122300000X
IL019.031873122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist