Provider Demographics
NPI:1134481229
Name:MALIK, RAHUL (DMD)
Entity Type:Individual
Prefix:
First Name:RAHUL
Middle Name:
Last Name:MALIK
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 1:2702 W DEYOUNG ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-4950
Mailing Address - Country:US
Mailing Address - Phone:205-639-7259
Mailing Address - Fax:
Practice Address - Street 1:2702 WEST DEYOUNG STREET
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959
Practice Address - Country:US
Practice Address - Phone:205-639-7259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029285122300000X
CT107761223G0001X
MADN18560101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice