Provider Demographics
NPI:1134505746
Name:MALLAIS DENTAL PLLC
Entity Type:Organization
Organization Name:MALLAIS DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRA
Authorized Official - Middle Name:SHANNON
Authorized Official - Last Name:MALLAIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:989-894-4611
Mailing Address - Street 1:1049 N PINE RD
Mailing Address - Street 2:
Mailing Address - City:ESSEXVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48732-1915
Mailing Address - Country:US
Mailing Address - Phone:989-894-4611
Mailing Address - Fax:989-894-2669
Practice Address - Street 1:1049 N PINE RD
Practice Address - Street 2:
Practice Address - City:ESSEXVILLE
Practice Address - State:MI
Practice Address - Zip Code:48732-1915
Practice Address - Country:US
Practice Address - Phone:989-894-4611
Practice Address - Fax:989-894-2669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010202581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty