Provider Demographics
NPI:1235731548
Name:DEEPLI MALLA DDS
Entity Type:Organization
Organization Name:DEEPLI MALLA DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SELF
Authorized Official - Prefix:DR
Authorized Official - First Name:DEEPLI
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:559-909-4354
Mailing Address - Street 1:2059 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:CA
Mailing Address - Zip Code:93662-3512
Mailing Address - Country:US
Mailing Address - Phone:559-909-4354
Mailing Address - Fax:
Practice Address - Street 1:2059 HIGH ST
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:CA
Practice Address - Zip Code:93662-3512
Practice Address - Country:US
Practice Address - Phone:559-896-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1114536570Medicaid