Provider Demographics
NPI:1851439251
Name:MANGELSON, MARK LEGRAND (DDS, MS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LEGRAND
Last Name:MANGELSON
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 S 700 E STE 8
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2573
Mailing Address - Country:US
Mailing Address - Phone:801-266-3519
Mailing Address - Fax:
Practice Address - Street 1:4010 S 700 E STE 8
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2573
Practice Address - Country:US
Practice Address - Phone:801-266-3519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14396999221223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics