Provider Demographics
NPI:1447424668
Name:ST LOUIS DENTAL IMPLANT GROUP
Entity Type:Organization
Organization Name:ST LOUIS DENTAL IMPLANT GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MANGELS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:636-970-0295
Mailing Address - Street 1:11222 TESSON FERRY RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-6963
Mailing Address - Country:US
Mailing Address - Phone:314-729-7840
Mailing Address - Fax:
Practice Address - Street 1:3750 GREEN MOUNT CROSSING DR
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269
Practice Address - Country:US
Practice Address - Phone:314-729-7840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty