Provider Demographics
NPI:1023539947
Name:MANGROLA, PRIYAL P (DMD)
Entity Type:Individual
Prefix:
First Name:PRIYAL
Middle Name:P
Last Name:MANGROLA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9727 KEELER AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1129
Mailing Address - Country:US
Mailing Address - Phone:281-889-7688
Mailing Address - Fax:
Practice Address - Street 1:1125 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-2337
Practice Address - Country:US
Practice Address - Phone:708-386-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-30
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017021966122300000X
IL0210030781223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentistGroup - Single Specialty