Provider Demographics
NPI:1316260854
Name:MANGAN, STEPHEN JAMES (DMD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JAMES
Last Name:MANGAN
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 1:1111 SE 5TH CT
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-3005
Mailing Address - Country:US
Mailing Address - Phone:954-655-0251
Mailing Address - Fax:
Practice Address - Street 1:1625 E LAS OLAS BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-2357
Practice Address - Country:US
Practice Address - Phone:954-463-5051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN187771223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics