Provider Demographics
NPI:1760513360
Name:MANGLAVITI, RONALD RICHARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:RICHARD
Last Name:MANGLAVITI
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:PO BOX 335
Mailing Address - Street 2:
Mailing Address - City:LAKE WINOLA
Mailing Address - State:PA
Mailing Address - Zip Code:18625-0335
Mailing Address - Country:US
Mailing Address - Phone:570-378-3305
Mailing Address - Fax:570-378-3430
Practice Address - Street 1:ROUTE 307
Practice Address - Street 2:
Practice Address - City:LAKE WINOLA
Practice Address - State:PA
Practice Address - Zip Code:18625-0335
Practice Address - Country:US
Practice Address - Phone:570-378-3305
Practice Address - Fax:570-378-3430
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS030229L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA980879OtherUNITED CONCORDIA
PA0017637470001Medicare ID - Type UnspecifiedMEDICAL ASSISTANCE