Provider Demographics
NPI:1598652075
Name:AHMAD, MALLAK (DMD)
Entity type:Individual
Prefix:
First Name:MALLAK
Middle Name:
Last Name:AHMAD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 SHADOW CREEK DR
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-2912
Mailing Address - Country:US
Mailing Address - Phone:708-590-9868
Mailing Address - Fax:
Practice Address - Street 1:402 SHADOW CREEK DR
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-2912
Practice Address - Country:US
Practice Address - Phone:708-590-9868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-18
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.036123122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist