Provider Demographics
NPI:1295409076
Name:LELAK, MALLORY WEAVER (DMD)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:WEAVER
Last Name:LELAK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 TIMBER SHADOWS DR BLDG A
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-2028
Mailing Address - Country:US
Mailing Address - Phone:281-359-9100
Mailing Address - Fax:
Practice Address - Street 1:2325 TIMBER SHADOWS DR BLDG A
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-2028
Practice Address - Country:US
Practice Address - Phone:281-359-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1224531223G0001X
TX37692122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty