Provider Demographics
NPI:1578697546
Name:MANGRUM, YOLANDA MARYE (DDS)
Entity Type:Individual
Prefix:DR
First Name:YOLANDA
Middle Name:MARYE
Last Name:MANGRUM
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 1:1301 SOUTHPOINT BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-6858
Mailing Address - Country:US
Mailing Address - Phone:707-762-0067
Mailing Address - Fax:707-762-4782
Practice Address - Street 1:1301 SOUTHPOINT BLVD STE A
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-6858
Practice Address - Country:US
Practice Address - Phone:707-762-0067
Practice Address - Fax:707-762-4782
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA446121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice