Provider Demographics
NPI:1558433524
Name:J. BRETT MANGUM DDS PC
Entity Type:Organization
Organization Name:J. BRETT MANGUM DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:BRETT
Authorized Official - Last Name:MANGUM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:928-778-4110
Mailing Address - Street 1:1767 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1154
Mailing Address - Country:US
Mailing Address - Phone:928-778-4110
Mailing Address - Fax:928-778-4114
Practice Address - Street 1:1767 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1154
Practice Address - Country:US
Practice Address - Phone:928-778-4110
Practice Address - Fax:928-778-4114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD55631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty