Provider Demographics
NPI:1528739968
Name:MANSOUR, MAHTAB (DE 61198534)
Entity type:Individual
Prefix:
First Name:MAHTAB
Middle Name:
Last Name:MANSOUR
Suffix:
Gender:F
Credentials:DE 61198534
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 MARTIN WAY E STE 101
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98516-5325
Mailing Address - Country:US
Mailing Address - Phone:360-455-9544
Mailing Address - Fax:
Practice Address - Street 1:4210 MARTIN WAY E STE 101
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98516-5325
Practice Address - Country:US
Practice Address - Phone:360-455-9544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61198534122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist