Provider Demographics
NPI:1275776684
Name:MANGRUM DENTAL CORPORATION
Entity Type:Organization
Organization Name:MANGRUM DENTAL CORPORATION
Other - Org Name:PETALUMA DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:QUACKENBUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-762-0067
Mailing Address - Street 1:1430 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-3631
Mailing Address - Country:US
Mailing Address - Phone:707-762-0067
Mailing Address - Fax:707-762-4782
Practice Address - Street 1:1430 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-3631
Practice Address - Country:US
Practice Address - Phone:707-762-0067
Practice Address - Fax:707-762-4782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-15
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA446121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty