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General NPI Number Information
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NPI Number | 1619454287
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Entity Type | Individual
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Provider Name | CALEB MANGUM
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Gender | Male
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Dates
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Enumeration Date | 07/25/2018
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Last Update Date | 07/25/2018
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Provider Practice Location Address
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Address Line | 4685 ELDORADO PKWY STE 200
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City | FRISCO
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State | TX
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Zip | 75033-0290
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Country | US
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Telephone | 214-618-5450
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Fax |
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Provider Business Mailing Address
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Address Line | 17712 RIVER CHASE DR
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City | DALLAS
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State | TX
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Zip | 75287-6265
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Country | US
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Telephone | 505-301-4473
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 34039
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License Number State | TX
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