Provider Demographics
NPI:1174707772
Name:MANGELSDORF FAMILY DENTISTRY
Entity type:Organization
Organization Name:MANGELSDORF FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MANGELSDORF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:928-718-2136
Mailing Address - Street 1:2249 HUALAPAI MOUNTAIN RD STE A
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-8321
Mailing Address - Country:US
Mailing Address - Phone:928-718-2136
Mailing Address - Fax:928-718-2137
Practice Address - Street 1:2249 HUALAPAI MOUNTAIN RD STE A
Practice Address - Street 2:
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:928-718-2137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3751261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1619924669OtherNPI FOR INDIVIDUAL