Provider Demographics
NPI:1508363391
Name:M MALLEMPALLI PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:M MALLEMPALLI PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST(PRESIDENT)
Authorized Official - Prefix:DR
Authorized Official - First Name:MANIMANJARI
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLEMPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-586-7056
Mailing Address - Street 1:11412 FAIRWIND COURT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 PALM AVE.
Practice Address - Street 2:SUITE#116
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932
Practice Address - Country:US
Practice Address - Phone:619-628-8123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA495861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty