Provider Demographics
NPI:1245398114
Name:MALLINAK, RAYMOND FRANK (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:FRANK
Last Name:MALLINAK
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:PO BOX 3966
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24115-3966
Mailing Address - Country:US
Mailing Address - Phone:276-632-2189
Mailing Address - Fax:276-638-2306
Practice Address - Street 1:604 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-3008
Practice Address - Country:US
Practice Address - Phone:276-632-2189
Practice Address - Fax:276-638-2306
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010052361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9178603Medicaid