Provider Demographics
NPI:1265198618
Name:MANGOLEAF DENTAL PLLC
Entity type:Organization
Organization Name:MANGOLEAF DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-228-2250
Mailing Address - Street 1:3501 FM 407 E STE 200
Mailing Address - Street 2:
Mailing Address - City:LANTANA
Mailing Address - State:TX
Mailing Address - Zip Code:76226-9769
Mailing Address - Country:US
Mailing Address - Phone:940-489-1660
Mailing Address - Fax:972-408-0736
Practice Address - Street 1:3501 FM 407 E STE 200
Practice Address - Street 2:
Practice Address - City:LANTANA
Practice Address - State:TX
Practice Address - Zip Code:76226-9769
Practice Address - Country:US
Practice Address - Phone:940-489-1660
Practice Address - Fax:972-408-0736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty