MEDICARE: PRIYAL P MANGROLA DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	2017021966	MO
2	1223P0221X	Pediatric Dentistry	021003078	IL

General Provider Information

NPI Number	:	1023539947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRIYAL P MANGROLA DMD

Provider Business Mailing Address
First Line	:	9727 KEELER AVE
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60076-1129
Country	:	US
Telephone Number	:	281-889-7688
Fax Number	:

Provider Business Practice Location Address
First Line	:	810 S WAUKEGAN RD STE 101
Second Line	:
City	:	LAKE FOREST
State	:	IL
Zip	:	60045-2672
Country	:	US
Telephone Number	:	847-615-5437
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2017
Last Update Date	:	09/18/2024

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