Provider Demographics
NPI:1982150264
Name:MANGELSDORF, JESSE ISAAC (DDS)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:ISAAC
Last Name:MANGELSDORF
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 1:2499 HUALAPAI MOUNTAIN
Mailing Address - Street 2:A
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401
Mailing Address - Country:US
Mailing Address - Phone:928-718-2136
Mailing Address - Fax:
Practice Address - Street 1:2249 HUALAPAI MOUNTAIN RD
Practice Address - Street 2:SUITE A
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-8321
Practice Address - Country:US
Practice Address - Phone:928-718-2136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9535122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist