Provider Demographics
NPI:1578971891
Name:MALAMEL, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MALAMEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3009 127TH PL SE
Mailing Address - Street 2:APT C22
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-4344
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10414 BEARDSLEE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3205
Practice Address - Country:US
Practice Address - Phone:425-424-6353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-30
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARR604915981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice