Provider Demographics
NPI:1396992699
Name:MANGRUM, KELLY A (DDS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:MANGRUM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7L110 SOUTH HIGHLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84121
Mailing Address - Country:US
Mailing Address - Phone:801-943-6880
Mailing Address - Fax:801-943-4744
Practice Address - Street 1:7110 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84121-3704
Practice Address - Country:US
Practice Address - Phone:801-943-6880
Practice Address - Fax:801-943-4744
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT26631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice