Provider Demographics
NPI:1003928375
Name:MALLERY, MARTINA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARTINA
Middle Name:
Last Name:MALLERY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:846 S OSPREY AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236-7883
Mailing Address - Country:US
Mailing Address - Phone:941-706-1505
Mailing Address - Fax:941-554-8172
Practice Address - Street 1:846 S OSPREY AVE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-7883
Practice Address - Country:US
Practice Address - Phone:941-706-1505
Practice Address - Fax:941-554-8172
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA526441223G0001X
FLDN185311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice