Provider Demographics
NPI:1922664556
Name:SALT LAKE IMPLANTS AND PERIODONTICS
Entity Type:Organization
Organization Name:SALT LAKE IMPLANTS AND PERIODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-266-3519
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:84107-2582
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:84107-2582
Practice Address - Country:US
Practice Address - Phone:801-266-3519
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty