Healthcare Provider Details

I. General information

NPI: 1376220517
Provider Name (Legal Business Name): CYRUS JON MANSOURI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5024 KEYSTONE BLVD STE A
COVINGTON LA
70433-7517
US

IV. Provider business mailing address

6377 CANAL BLVD
NEW ORLEANS LA
70124-3117
US

V. Phone/Fax

Practice location:
  • Phone: 985-778-0241
  • Fax:
Mailing address:
  • Phone: 224-456-9191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number7473
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: