Provider Demographics
NPI:1548413099
Name:MALLORY, LORI (RDH)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:MALLORY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 W BRANCH ST STE A
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-2601
Mailing Address - Country:US
Mailing Address - Phone:805-481-6617
Mailing Address - Fax:805-481-3829
Practice Address - Street 1:121 W BRANCH ST STE A
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-2601
Practice Address - Country:US
Practice Address - Phone:805-481-6617
Practice Address - Fax:805-481-3829
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18017124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist