Basic Information
| Provider Information | |||||||||
| NPI: | 1376165928 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALLICK | ||||||||
| FirstName: | OMEIR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32 DOOLIN BAY DRIVE | ||||||||
| Address2: | |||||||||
| City: | BEAR | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197016370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3023676857 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 138 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | HANOVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173312500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176328571 | ||||||||
| FaxNumber: | 7176326466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2020 | ||||||||
| LastUpdateDate: | 03/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DS043118 | PA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 103892011 | 05 | PA | MEDICAID |