MEDICARE: DR. AZITA AGHARAHIMI MANSOURI D.M.D.

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	DN013537	GA

General Provider Information

NPI Number	:	1821288226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AZITA AGHARAHIMI MANSOURI D.M.D.

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

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

Provider Enumeration Date	:	07/31/2007
Last Update Date	:	06/18/2008

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