MEDICARE: MR. CHARLES STEVEN MANGAN III D.D.S.

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	1223G0001X	General Practice Dentistry	AR2807	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	662941	OTHER	AR	UNITED CONCORDIA
2	58242	OTHER	AR	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1144365446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES STEVEN MANGAN III D.D.S.

Provider Business Mailing Address
First Line	:	2011 N VAN BUREN ST
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72207-4739
Country	:	US
Telephone Number	:	501-666-1188
Fax Number	:	501-666-1189

Provider Business Practice Location Address
First Line	:	2011 N VAN BUREN ST
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72207-4739
Country	:	US
Telephone Number	:	501-666-1188
Fax Number	:	501-666-1189

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

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	07/08/2007

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