Provider Demographics
NPI:1548795883
Name:THAO, MALIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MALIA
Middle Name:
Last Name:THAO
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 1:8215 GREENWAY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-3686
Mailing Address - Country:US
Mailing Address - Phone:608-827-6453
Mailing Address - Fax:
Practice Address - Street 1:8215 GREENWAY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-3686
Practice Address - Country:US
Practice Address - Phone:608-827-6453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10015811223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice