Provider Demographics
NPI:1184453268
Name:MANGONON, SOPHIA (DMD)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:MANGONON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BOUCLE JEANNE CIR APT 155
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-6618
Mailing Address - Country:US
Mailing Address - Phone:561-685-9844
Mailing Address - Fax:
Practice Address - Street 1:2500 W LAKE MARY BLVD STE 106
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3501
Practice Address - Country:US
Practice Address - Phone:407-328-6411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL294351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice