Healthcare Provider Details

I. General information

NPI: 1851439251
Provider Name (Legal Business Name): MARK LEGRAND MANGELSON DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 S 700 E STE 8
SALT LAKE CITY UT
84107-2573
US

IV. Provider business mailing address

4010 S 700 E STE 8
SALT LAKE CITY UT
84107-2573
US

V. Phone/Fax

Practice location:
  • Phone: 801-266-3519
  • Fax:
Mailing address:
  • Phone: 801-266-3519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number1439699922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: