Provider Demographics
NPI:1457465809
Name:MALLOUH, JOSEPH (DDS)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:MALLOUH
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 130
Mailing Address - Street 2:
Mailing Address - City:SLATERSVILLE
Mailing Address - State:RI
Mailing Address - Zip Code:02876-0130
Mailing Address - Country:US
Mailing Address - Phone:401-766-2800
Mailing Address - Fax:401-765-2858
Practice Address - Street 1:747 VICTORY HWY
Practice Address - Street 2:
Practice Address - City:SLATERSVILLE
Practice Address - State:RI
Practice Address - Zip Code:02876-0130
Practice Address - Country:US
Practice Address - Phone:401-766-2805
Practice Address - Fax:401-765-2858
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN02664122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI8591-3OtherBLUE CROSS DENTAL RI
MARG 0130OtherBLUE CROSS MA DENTAL