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General NPI Number Information
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NPI Number | 1265198618
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Entity Type | Organization
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Legal Business Name | MANGOLEAF DENTAL PLLC
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Dates
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Enumeration Date | 11/10/2021
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Last Update Date | 11/10/2021
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Provider Practice Location Address
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Address Line | 3501 FM 407 E STE 200
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City | LANTANA
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State | TX
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Zip | 76226-9769
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Country | US
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Telephone | 940-489-1660
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Fax | 972-408-0736
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Provider Business Mailing Address
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Address Line | 3501 FM 407 E STE 200
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City | LANTANA
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State | TX
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Zip | 76226-9769
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Country | US
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Telephone | 940-489-1660
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Fax | 972-408-0736
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | JEREMY FREEMAN
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Credential |
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Telephone | 940-228-2250
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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