Provider Demographics
NPI:1114095478
Name:MALAKI, MORAD R (DMD)
Entity Type:Individual
Prefix:MR
First Name:MORAD
Middle Name:R
Last Name:MALAKI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1739 E BROADWAY RD
Mailing Address - Street 2:STE #171
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282
Mailing Address - Country:US
Mailing Address - Phone:267-235-9074
Mailing Address - Fax:602-242-4267
Practice Address - Street 1:3608 W CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85019
Practice Address - Country:US
Practice Address - Phone:602-544-2480
Practice Address - Fax:602-242-4267
Is Sole Proprietor?:No
Enumeration Date:2006-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD5701122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ715245Medicaid