Provider Demographics
NPI:1376165928
Name:MALLICK, OMEIR (DDS)
Entity Type:Individual
Prefix:MR
First Name:OMEIR
Middle Name:
Last Name:MALLICK
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 1:32 DOOLIN BAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701-6370
Mailing Address - Country:US
Mailing Address - Phone:302-367-6857
Mailing Address - Fax:
Practice Address - Street 1:138 BROADWAY
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331-2500
Practice Address - Country:US
Practice Address - Phone:717-632-8571
Practice Address - Fax:717-632-6466
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-16
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS043118122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103892011Medicaid