Provider Demographics
NPI:1609156777
Name:MANGINO, MICHAEL JOSEPH (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:MANGINO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 S 28TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3808
Mailing Address - Country:US
Mailing Address - Phone:270-444-4041
Mailing Address - Fax:270-444-7319
Practice Address - Street 1:408 S 28TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3808
Practice Address - Country:US
Practice Address - Phone:270-444-4041
Practice Address - Fax:270-444-7319
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-22
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY91451223G0001X
OH300235511223G0001X
IN12011881A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice