Provider Demographics
NPI:1215516919
Name:MANSURI, MUSTAPHA
Entity type:Individual
Prefix:
First Name:MUSTAPHA
Middle Name:
Last Name:MANSURI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12816 FRAIZER ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-3505
Mailing Address - Country:US
Mailing Address - Phone:651-529-5005
Mailing Address - Fax:
Practice Address - Street 1:8454 HIGHWAY 7
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-3900
Practice Address - Country:US
Practice Address - Phone:952-933-3667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND145431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice