Provider Demographics
NPI:1245783265
Name:MANGAT, JASKIRAT
Entity Type:Individual
Prefix:
First Name:JASKIRAT
Middle Name:
Last Name:MANGAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S TULPEHOCKEN ST
Mailing Address - Street 2:
Mailing Address - City:PINE GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17963-1014
Mailing Address - Country:US
Mailing Address - Phone:570-345-8007
Mailing Address - Fax:
Practice Address - Street 1:210 SOUTH TULPEHOCKEN STREET
Practice Address - Street 2:
Practice Address - City:PINE GROVE
Practice Address - State:PA
Practice Address - Zip Code:17963-8935
Practice Address - Country:US
Practice Address - Phone:570-345-8007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0408831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice