Provider Demographics
NPI:1518080597
Name:JUSTIN, IRENE MALAVIKA (DDS)
Entity Type:Individual
Prefix:DR
First Name:IRENE
Middle Name:MALAVIKA
Last Name:JUSTIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10186 MONACO PL
Mailing Address - Street 2:
Mailing Address - City:RANCHOCUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91737
Mailing Address - Country:US
Mailing Address - Phone:951-536-8419
Mailing Address - Fax:
Practice Address - Street 1:10186 MONACO PL
Practice Address - Street 2:
Practice Address - City:RANCHOCUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91737
Practice Address - Country:US
Practice Address - Phone:951-536-8419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA510841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice