Provider Demographics
NPI:1336294982
Name:JALLAD, MARWAN M (DDS)
Entity Type:Individual
Prefix:MR
First Name:MARWAN
Middle Name:M
Last Name:JALLAD
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 1:14 DOSCHER AVENUE
Mailing Address - Street 2:
Mailing Address - City:WEST NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10994
Mailing Address - Country:US
Mailing Address - Phone:845-727-4124
Mailing Address - Fax:845-727-4128
Practice Address - Street 1:14 DOSCHER AVENUE
Practice Address - Street 2:
Practice Address - City:WEST NYACK
Practice Address - State:NY
Practice Address - Zip Code:10994
Practice Address - Country:US
Practice Address - Phone:845-727-4124
Practice Address - Fax:845-727-4128
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043263122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01283421Medicaid