Basic Information
| Provider Information | |||||||||
| NPI: | 1356902480 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALLIC | ||||||||
| FirstName: | MALEEHA | ||||||||
| MiddleName: | ISHAAK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2869 MYRTLEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | DUMFRIES | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220264533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5408401661 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1251B SARATOGA AVE NE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200181025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024694699 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2019 | ||||||||
| LastUpdateDate: | 08/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DEN1002121 | DC | Y | Dental Providers | Dentist | 122300000X | DS042290 | PA | N | Dental Providers | Dentist |
No ID Information.