Provider Demographics
NPI:1942782594
Name:MONGALO, MARCO ANTONIO (DDS)
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:ANTONIO
Last Name:MONGALO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2684 CAHILL WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2322
Mailing Address - Country:US
Mailing Address - Phone:407-634-8544
Mailing Address - Fax:
Practice Address - Street 1:2684 CAHILL WAY
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2322
Practice Address - Country:US
Practice Address - Phone:407-634-8544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN11409122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist