Provider Demographics
NPI:1265126148
Name:MANG, ROBERT AUSTIN (DMD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:AUSTIN
Last Name:MANG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 DURBIN PAVILION DR STE 112
Mailing Address - Street 2:
Mailing Address - City:ST JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-4121
Mailing Address - Country:US
Mailing Address - Phone:904-325-7276
Mailing Address - Fax:
Practice Address - Street 1:70 DURBIN PAVILION DR STE 112
Practice Address - Street 2:
Practice Address - City:ST JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-4121
Practice Address - Country:US
Practice Address - Phone:904-325-7276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN28010122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist