Provider Demographics
NPI:1164546669
Name:MALLOUHI, MARY FARES (DDS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:FARES
Last Name:MALLOUHI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:394 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-5805
Mailing Address - Country:US
Mailing Address - Phone:201-525-0067
Mailing Address - Fax:201-525-0070
Practice Address - Street 1:394 MAIN ST
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-5805
Practice Address - Country:US
Practice Address - Phone:201-525-0067
Practice Address - Fax:201-525-0070
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI217031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0114031Medicaid