Provider Demographics
NPI:1265082077
Name:MANGANO, DYLAN
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:MANGANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 LONG ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WYANDANCH
Mailing Address - State:NY
Mailing Address - Zip Code:11798-3015
Mailing Address - Country:US
Mailing Address - Phone:631-920-8250
Mailing Address - Fax:631-920-8251
Practice Address - Street 1:234 LONG ISLAND AVE
Practice Address - Street 2:
Practice Address - City:WYANDANCH
Practice Address - State:NY
Practice Address - Zip Code:11798-3015
Practice Address - Country:US
Practice Address - Phone:631-920-8250
Practice Address - Fax:631-920-8251
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-13
Last Update Date:2024-10-22
Deactivation Date:2024-10-16
Deactivation Code:
Reactivation Date:2024-10-22
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program