Provider Demographics
NPI:1194715011
Name:MANSOUR, RAFAT M (DDS)
Entity type:Individual
Prefix:DR
First Name:RAFAT
Middle Name:M
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:RAY
Other - Middle Name:
Other - Last Name:MANSOUR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1010 BRIDGE BLVD SW
Mailing Address - Street 2:SUITE E
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-3765
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 BRIDGE BLVD SW
Practice Address - Street 2:SUITE E
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-3765
Practice Address - Country:US
Practice Address - Phone:505-877-0435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD21031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1002823Medicaid