Healthcare Provider Details

I. General information

NPI: 1487798856
Provider Name (Legal Business Name): KENNETH MANGANO, DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8025 RITCHIE HWY SUITE 204
PASADENA MD
21122-1031
US

IV. Provider business mailing address

8025 RITCHIE HWY SUITE 204
PASADENA MD
21122-1031
US

V. Phone/Fax

Practice location:
  • Phone: 410-766-3453
  • Fax: 410-766-3454
Mailing address:
  • Phone: 410-766-3453
  • Fax: 410-766-3454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12584
License Number StateMD

VIII. Authorized Official

Name: DR. KENNETH MANGNANO
Title or Position: PRESIDENT
Credential: DDS
Phone: 410-766-3453