=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285032789
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMAN DENTAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2014
-----------------------------------------------------
Last Update Date | 12/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 N CONWAY AVE
-----------------------------------------------------
City | MISSION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78572-5361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-553-5802
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 N CONWAY AVE
-----------------------------------------------------
City | MISSION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78572-5361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-553-5802
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DDS/OWNER
-----------------------------------------------------
Name | DR. AHMAND AL MANASIR
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 714-553-5802
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 28839
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------