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General NPI Number Information
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NPI Number | 1659779569
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Entity Type | Organization
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Legal Business Name | MANGRAM DENTAL, P.C.
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Dates
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Enumeration Date | 12/09/2014
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Last Update Date | 12/09/2014
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Provider Practice Location Address
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Address Line | 647 W LINCOLN HWY SUITE B
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City | CHICAGO HEIGHTS
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State | IL
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Zip | 60411-2374
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Country | US
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Telephone | 708-996-1111
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Fax |
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Provider Business Mailing Address
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Address Line | 1321 ROSEWOOD CT
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City | FLOSSMOOR
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State | IL
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Zip | 60422-1471
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Country | US
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Telephone | 708-799-4203
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/DENTIST
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Name | DR. TRENEICE MANGRAM
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Credential | D.D.S.
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Telephone | 708-799-4203
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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 | 019026308
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License Number State | IL
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