Provider Demographics
NPI:1619454287
Name:MANGUM, CALEB
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:
Last Name:MANGUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17712 RIVER CHASE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-6265
Mailing Address - Country:US
Mailing Address - Phone:505-301-4473
Mailing Address - Fax:
Practice Address - Street 1:4685 ELDORADO PKWY STE 200
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-0290
Practice Address - Country:US
Practice Address - Phone:214-618-5450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX340391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice