Provider Demographics
NPI:1679175541
Name:LEGACY DENTAL LLC
Entity type:Organization
Organization Name:LEGACY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SAMER
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:814-746-3327
Mailing Address - Street 1:5127 ZUCK RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-4941
Mailing Address - Country:US
Mailing Address - Phone:814-746-3327
Mailing Address - Fax:
Practice Address - Street 1:5127 ZUCK RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-4941
Practice Address - Country:US
Practice Address - Phone:814-746-3327
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-14
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty