Provider Demographics
NPI:1649426560
Name:MANSHADI, NIEKU (DDS)
Entity type:Individual
Prefix:DR
First Name:NIEKU
Middle Name:
Last Name:MANSHADI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8716 RESEARCH BLVD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-6420
Mailing Address - Country:US
Mailing Address - Phone:512-454-4646
Mailing Address - Fax:
Practice Address - Street 1:8716 RESEARCH BLVD
Practice Address - Street 2:SUITE 125
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-6420
Practice Address - Country:US
Practice Address - Phone:512-454-4646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA564771223P0221X
NY0595601223P0221X
TX248701223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05154687Medicaid
TX204782102Medicaid