Healthcare Provider Details

I. General information

NPI: 1215945415
Provider Name (Legal Business Name): MARK ALAN MANGELS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 01/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MID RIVERS MALL DR SUITE 370
SAINT PETERS MO
63376-4320
US

IV. Provider business mailing address

521 N CENTRAL AVE
SAINT LOUIS MO
63130-3907
US

V. Phone/Fax

Practice location:
  • Phone: 636-970-0295
  • Fax: 636-278-3033
Mailing address:
  • Phone: 618-593-1438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2005013969
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: