Provider Demographics
NPI:1447475140
Name:MANSSURI, FEREIDON WOLFGANG (DDS)
Entity type:Individual
Prefix:
First Name:FEREIDON
Middle Name:WOLFGANG
Last Name:MANSSURI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:WOLFGANG
Other - Middle Name:
Other - Last Name:MANSSURI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:134 COURSEVALL DRIVE
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21617
Mailing Address - Country:US
Mailing Address - Phone:410-758-1424
Mailing Address - Fax:410-758-4380
Practice Address - Street 1:134 COURSEVALL DRIVE
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MD
Practice Address - Zip Code:21617
Practice Address - Country:US
Practice Address - Phone:410-758-1424
Practice Address - Fax:410-758-4380
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12053122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist