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General NPI Number Information
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NPI Number | 1497959894
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Entity Type | Organization
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Legal Business Name | MARK MANGELS, DMD, LLC
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Dates
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Enumeration Date | 06/12/2007
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Last Update Date | 11/01/2007
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Provider Practice Location Address
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Address Line | 1 MID RIVERS MALL DR SUITE 370
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City | SAINT PETERS
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State | MO
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Zip | 63376-4320
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Country | US
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Telephone | 636-970-0295
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Fax |
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Provider Business Mailing Address
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Address Line | 1 MID RIVERS MALL DR SUITE 370
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City | SAINT PETERS
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State | MO
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Zip | 63376-4320
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Country | US
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Telephone | 636-970-0295
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARK ALAN MANGELS
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Credential | DMD
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Telephone | 636-970-0295
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 013969
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License Number State | MO
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