Provider Demographics
NPI:1700498607
Name:MANGARIN, ZACHARY MICHAEL (RDH)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:MICHAEL
Last Name:MANGARIN
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 6TH AVE APT C102
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033-5685
Mailing Address - Country:US
Mailing Address - Phone:562-371-5032
Mailing Address - Fax:
Practice Address - Street 1:1112 S CUSHMAN AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-3631
Practice Address - Country:US
Practice Address - Phone:253-593-2144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61005381124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherEMPLOYEE OF SEA MAR