Healthcare Provider Details

I. General information

NPI: 1497493142
Provider Name (Legal Business Name): ERIK LEGRAND MANGELSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2022
Last Update Date: 07/22/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HAWKINS DR
IOWA CITY IA
52242-1009
US

IV. Provider business mailing address

51300 POMERANTZ FAMILY PAVILION
IOWA CITY IA
52242-1049
US

V. Phone/Fax

Practice location:
  • Phone: 319-356-7339
  • Fax: 319-353-6923
Mailing address:
  • Phone: 193-356-2205
  • Fax: 319-335-8956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberRES-30630
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberRES-30630
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRES-30630
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: