Provider Demographics
NPI:1164737300
Name:MALLAIS, TERRA SHANNON (DDS)
Entity Type:Individual
Prefix:
First Name:TERRA
Middle Name:SHANNON
Last Name:MALLAIS
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:PO BOX 527
Mailing Address - Street 2:305 N. STATE STREET
Mailing Address - City:OSCODA
Mailing Address - State:MI
Mailing Address - Zip Code:48750-0527
Mailing Address - Country:US
Mailing Address - Phone:989-739-8878
Mailing Address - Fax:989-739-0284
Practice Address - Street 1:305 N STATE ST
Practice Address - Street 2:
Practice Address - City:OSCODA
Practice Address - State:MI
Practice Address - Zip Code:48750-1717
Practice Address - Country:US
Practice Address - Phone:989-739-8878
Practice Address - Fax:989-739-0284
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020258122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist