MEDICARE: ENGELLA SAMAR 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	122300000X	Dentist	42615	CA

General Provider Information

NPI Number	:	1871506360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ENGELLA SAMAR MANSOUR DDS

Provider Business Mailing Address
First Line	:	1324 GARNET AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-3011
Country	:	US
Telephone Number	:	619-275-2750
Fax Number	:	619-275-1935

Provider Business Practice Location Address
First Line	:	1324 GARNET AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-3011
Country	:	US
Telephone Number	:	619-275-2750
Fax Number	:	619-275-1935

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

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	08/03/2016

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