Provider Demographics
NPI:1447865480
Name:MANGELSDORF, LUKE MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:LUKE
Middle Name:MICHAEL
Last Name:MANGELSDORF
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 1:2249 HUALAPAI MOUNTAIN RD STE 1
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:
Practice Address - Street 1:2249 HUALAPAI MOUNTAIN RD STE 1
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:
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD010867122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist