Provider Demographics
NPI:1093836793
Name:MALLI, MANPREET REVA (DDS)
Entity Type:Individual
Prefix:MRS
First Name:MANPREET
Middle Name:REVA
Last Name:MALLI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:MANPREET
Other - Middle Name:REVA
Other - Last Name:GREWAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:233 N. M STREET
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93274
Mailing Address - Country:US
Mailing Address - Phone:559-688-7529
Mailing Address - Fax:559-688-1223
Practice Address - Street 1:233 N. M STREET
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274
Practice Address - Country:US
Practice Address - Phone:559-688-7529
Practice Address - Fax:559-688-1223
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53218122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist