Provider Demographics
NPI:1710480629
Name:MANGAT, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:MANGAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1385 HIDDEN RANCH DR
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-4564
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1385 HIDDEN RANCH DR
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-4564
Practice Address - Country:US
Practice Address - Phone:805-304-9970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101131122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist