Healthcare Provider Details

I. General information

NPI: 1912528548
Provider Name (Legal Business Name): PARTH MANGROLA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2020
Last Update Date: 05/05/2020
Certification Date: 05/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3320 RUTGER ST
SAINT LOUIS MO
63104-1122
US

IV. Provider business mailing address

9727 KEELER AVE
SKOKIE IL
60076-1129
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-8381
  • Fax:
Mailing address:
  • Phone: 847-373-2744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number019.031236
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: