MEDICARE: LAWRENCEVILLE FAMILY DENTAL CARE, P.C.

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

General Provider Information

NPI Number	:	1699948463
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAWRENCEVILLE FAMILY DENTAL CARE, P.C.

Provider Business Mailing Address
First Line	:	2401 LAWRENCEVILLE HWY STE A
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30044-4411
Country	:	US
Telephone Number	:	770-962-1977
Fax Number	:	770-962-9886

Provider Business Practice Location Address
First Line	:	2401 LAWRENCEVILLE HWY STE A
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30044-4411
Country	:	US
Telephone Number	:	770-962-1977
Fax Number	:	770-962-9886

Authorized Official
Title or Position	:	PRESIDENT/DENTIST
Name	:	DR. MICHAEL S MANSOURI
Credential	:	DMD
Telephone Number	:	770-962-0014

Provider Enumeration Date	:	04/11/2008
Last Update Date	:	04/11/2008

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