Provider Demographics
NPI:1154531432
Name:NATALIE MANSOUR DMD DENTAL CORP
Entity type:Organization
Organization Name:NATALIE MANSOUR DMD DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:CHANTAL
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:310-902-7775
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:310-902-7775
Mailing Address - Fax:310-858-8333
Practice Address - Street 1:709 S CENTRAL AVE
Practice Address - Street 2:SUITE A
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2010
Practice Address - Country:US
Practice Address - Phone:818-500-7330
Practice Address - Fax:818-500-7340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA493741223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty