Provider Demographics
NPI:1114946670
Name:MALIS, GERALD W (DDS)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:W
Last Name:MALIS
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 1:2202 1/2 ALGONQUIN RD
Mailing Address - Street 2:
Mailing Address - City:ROLLING MEADOWS
Mailing Address - State:IL
Mailing Address - Zip Code:60008-3608
Mailing Address - Country:US
Mailing Address - Phone:847-870-0888
Mailing Address - Fax:847-870-0897
Practice Address - Street 1:2202 1/2 ALGONQUIN RD
Practice Address - Street 2:
Practice Address - City:ROLLING MEADOWS
Practice Address - State:IL
Practice Address - Zip Code:60008-3608
Practice Address - Country:US
Practice Address - Phone:847-870-0888
Practice Address - Fax:847-870-0897
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice