Provider Demographics
NPI:1962562306
Name:MANSOUR, MALEK K (DDS, MAGD PHD)
Entity type:Individual
Prefix:DR
First Name:MALEK
Middle Name:K
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:DDS, MAGD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 ODYSSEY
Mailing Address - Street 2:SUITE 265
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3186
Mailing Address - Country:US
Mailing Address - Phone:949-585-1515
Mailing Address - Fax:949-585-1515
Practice Address - Street 1:22 ODYSSEY
Practice Address - Street 2:SUITE 265
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3186
Practice Address - Country:US
Practice Address - Phone:949-585-1515
Practice Address - Fax:949-585-1515
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice