Provider Demographics
NPI:1124386172
Name:DOMBROCK, MALLORI BETH (DC)
Entity Type:Individual
Prefix:DR
First Name:MALLORI
Middle Name:BETH
Last Name:DOMBROCK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21450 HIGHWAY 7
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-7205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21450 HIGHWAY 7
Practice Address - Street 2:
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-7205
Practice Address - Country:US
Practice Address - Phone:952-474-9393
Practice Address - Fax:952-474-2375
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-27
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5909111NP0017X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NP0017XChiropractic ProvidersChiropractorPediatric Chiropractor