Provider Demographics
NPI:1063512192
Name:MALLERY DENTAL CORPORATION
Entity Type:Organization
Organization Name:MALLERY DENTAL CORPORATION
Other - Org Name:CAPISTRANO DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BUEHLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-487-3273
Mailing Address - Street 1:2860 MICHELLE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-1009
Mailing Address - Country:US
Mailing Address - Phone:714-508-3600
Mailing Address - Fax:714-368-2092
Practice Address - Street 1:31878 DEL OBISPO ST
Practice Address - Street 2:STE. 105
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3223
Practice Address - Country:US
Practice Address - Phone:949-487-3273
Practice Address - Fax:949-487-0322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA381661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty