Provider Demographics
NPI:1457466641
Name:MANG, DAT DULTIEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:DAT
Middle Name:DULTIEN
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 1:6658 78TH AVE NORTH
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33781
Mailing Address - Country:US
Mailing Address - Phone:727-209-0877
Mailing Address - Fax:727-209-0717
Practice Address - Street 1:6658 78TH AVE NORTH
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781
Practice Address - Country:US
Practice Address - Phone:727-209-0877
Practice Address - Fax:727-209-0717
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16638122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist