Provider Demographics
NPI:1447585997
Name:RAYMOND F. MALLINAK, DDS
Entity Type:Organization
Organization Name:RAYMOND F. MALLINAK, DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:MALLINAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:276-632-2189
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-15
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010052361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9178603Medicaid