Provider Demographics
NPI:1154446649
Name:NELSON-MANGATAL, JACQUELINE (DDS)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:NELSON-MANGATAL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7085 VIA LEONARDO
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-5236
Mailing Address - Country:US
Mailing Address - Phone:786-316-5044
Mailing Address - Fax:727-328-1971
Practice Address - Street 1:3011 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-8632
Practice Address - Country:US
Practice Address - Phone:786-316-5044
Practice Address - Fax:727-328-1971
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16582122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075681400Medicaid