Healthcare Provider Details

I. General information

NPI: 1447424668
Provider Name (Legal Business Name): ST LOUIS DENTAL IMPLANT GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 04/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3750 GREEN MOUNT CROSSING DR
SHILOH IL
62269
US

IV. Provider business mailing address

11222 TESSON FERRY RD
SAINT LOUIS MO
63123-6963
US

V. Phone/Fax

Practice location:
  • Phone: 314-729-7840
  • Fax:
Mailing address:
  • Phone: 314-729-7840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. MARK ALAN MANGELS
Title or Position: OWNER
Credential: DMD
Phone: 636-970-0295