Provider Demographics
NPI:1235362468
Name:MALLERY, MARK JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOHN
Last Name:MALLERY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 W ABRAM ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013
Mailing Address - Country:US
Mailing Address - Phone:817-461-5455
Mailing Address - Fax:817-460-2409
Practice Address - Street 1:1201 W ABRAM ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76013
Practice Address - Country:US
Practice Address - Phone:817-461-5455
Practice Address - Fax:817-460-2409
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-04
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24583122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist