Provider Demographics
NPI:1629813688
Name:MANSOUR, AYA
Entity type:Individual
Prefix:DR
First Name:AYA
Middle Name:
Last Name:MANSOUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38080 TAMARAC BLVD APT 206
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-3446
Mailing Address - Country:US
Mailing Address - Phone:812-706-9795
Mailing Address - Fax:
Practice Address - Street 1:29100 LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:WILLOWICK
Practice Address - State:OH
Practice Address - Zip Code:44095-4659
Practice Address - Country:US
Practice Address - Phone:812-706-9795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN251001223X0400X
IL019035024122300000X
OH30.0276861223X0400X
TX407421223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist