Basic Information
| Provider Information | |||||||||
| NPI: | 1538158043 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALLYA | ||||||||
| FirstName: | SANJAY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | B.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 951668 | ||||||||
| Address2: | CHS 10-165 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900951668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606792453 | ||||||||
| FaxNumber: | 8606792756 | ||||||||
| Practice Location | |||||||||
| Address1: | 10833 LE CONTE AVE | ||||||||
| Address2: | CHS 10-165 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900951668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108255634 | ||||||||
| FaxNumber: | 3102062748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 03/02/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0008X | 9026 | CT | N | Dental Providers | Dentist | Oral and Maxillofacial Radiology | 1223X0008X | SP-251 | CA | Y | Dental Providers | Dentist | Oral and Maxillofacial Radiology |
ID Information
| ID | Type | State | Issuer | Description | 004010807 | 05 | CT | MEDICAID |