Provider Demographics
NPI:1194925701
Name:MANSOUR, DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:DAVID
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 1:914 EMMETT ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-5436
Mailing Address - Country:US
Mailing Address - Phone:407-846-2150
Mailing Address - Fax:407-846-1960
Practice Address - Street 1:914 EMMETT ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5436
Practice Address - Country:US
Practice Address - Phone:407-846-2150
Practice Address - Fax:407-846-1960
Is Sole Proprietor?:No
Enumeration Date:2007-07-21
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 17959122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist