Provider Demographics
NPI:1053314872
Name:MALLOUK, PAUL MICHEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:MICHEL
Last Name:MALLOUK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:CA
Mailing Address - Zip Code:93215-1737
Mailing Address - Country:US
Mailing Address - Phone:661-725-9105
Mailing Address - Fax:661-720-9123
Practice Address - Street 1:1317 MAIN ST
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:CA
Practice Address - Zip Code:93215-1737
Practice Address - Country:US
Practice Address - Phone:661-725-9105
Practice Address - Fax:661-720-9123
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41025122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB41025Medicaid