Provider Demographics
NPI:1295939239
Name:MANGONDATO, JAMIL RIGOR (DMD)
Entity type:Individual
Prefix:
First Name:JAMIL
Middle Name:RIGOR
Last Name:MANGONDATO
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 1:35201 NEWARK BLVD
Mailing Address - Street 2:STE E
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560
Mailing Address - Country:US
Mailing Address - Phone:510-792-6396
Mailing Address - Fax:510-792-4687
Practice Address - Street 1:35201 NEWARK BLVD
Practice Address - Street 2:STE E
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560
Practice Address - Country:US
Practice Address - Phone:510-792-6396
Practice Address - Fax:510-792-4687
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48148122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist