Provider Demographics
NPI:1134349640
Name:MANGELS, JAMIE RANAE
Entity type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:RANAE
Last Name:MANGELS
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:JAMIE
Other - Middle Name:RANAE
Other - Last Name:PAUL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:521 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-3907
Mailing Address - Country:US
Mailing Address - Phone:618-541-8968
Mailing Address - Fax:
Practice Address - Street 1:709 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-2709
Practice Address - Country:US
Practice Address - Phone:636-239-2316
Practice Address - Fax:636-239-3316
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006021038122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist