Dental Board of California
Licensing details for: 17702
Name: PETALUMA DENTAL GROUP PRACTICE OF MANGRUM DENTAL CORPORATION
License Type: Fictitious Name Permit
Primary Status: Current - Active
Organization Classification: Corporation
Previous Names: Mangrum Dental Corporation
License Relationships
FNP Owners
License/Registration Role: Fictitious Name Permit
Related Party Role: Owners
Name: MANGRUM, YOLANDA MARYE
Address Not Disclosed
FNP to DDS or OMS
License/Registration Role: Fictitious Name Permit
Related Party Role: Must hold an active Dental License, or Oral Maxillofacial Surgery Permit
Name: MANGRUM, YOLANDA MARYE
License/Registration Type: Dentist License
License Number: 44612 Primary Status: Current - Active
Address :
1301 SOUTHPOINT BLVD
SUITE A
PETALUMA CA 94954
SONOMA COUNTY
