Provider Demographics
NPI:1043427289
Name:MALLETT, MARK RAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:RAY
Last Name:MALLETT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:11444 TORTUGA ST
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-5304
Mailing Address - Country:US
Mailing Address - Phone:562-596-1655
Mailing Address - Fax:562-799-9599
Practice Address - Street 1:3551 FARQUHAR AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2003
Practice Address - Country:US
Practice Address - Phone:562-596-1655
Practice Address - Fax:562-799-9599
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA19927122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist