Healthcare Provider Details

I. General information

NPI: 1841668100
Provider Name (Legal Business Name): KEVIN MANGELSON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2015
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10654 S RIVER HEIGHTS DR STE 240
SOUTH JORDAN UT
84095-5541
US

IV. Provider business mailing address

10654 S RIVER HEIGHTS DR STE 240
SOUTH JORDAN UT
84095-5541
US

V. Phone/Fax

Practice location:
  • Phone: 208-869-1696
  • Fax:
Mailing address:
  • Phone: 208-869-1696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9467504-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: