MEDICARE: DR. RAFAT M MANSOUR DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DD2103	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194715011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RAFAT M MANSOUR DDS

Provider Business Mailing Address
First Line	:	1010 BRIDGE BLVD SW
Second Line	:	SUITE E
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87105-3765
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1010 BRIDGE BLVD SW
Second Line	:	SUITE E
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87105-3765
Country	:	US
Telephone Number	:	505-877-0435
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2005
Last Update Date	:	05/25/2011

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