Provider Demographics
NPI:1588643134
Name:MALLORY, MARC P (DDS, PLLC)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:P
Last Name:MALLORY
Suffix:
Gender:M
Credentials:DDS, PLLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 E. WASHTENAW
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48933-1822
Mailing Address - Country:US
Mailing Address - Phone:517-487-5666
Mailing Address - Fax:517-267-0938
Practice Address - Street 1:107 E. WASHTENAW
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48933-1822
Practice Address - Country:US
Practice Address - Phone:517-487-5666
Practice Address - Fax:517-267-0938
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI144331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice