Provider Demographics
NPI:1629636220
Name:PAYNE, MALLORY ANNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:ANNE
Last Name:PAYNE
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 1:1910 CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-4182
Mailing Address - Country:US
Mailing Address - Phone:734-552-2656
Mailing Address - Fax:
Practice Address - Street 1:26113 HOOVER RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-1147
Practice Address - Country:US
Practice Address - Phone:586-393-5686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901023187122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist