Provider Demographics
NPI:1669851259
Name:YU, MALISA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MALISA
Middle Name:
Last Name:YU
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 1:100 E 15TH ST.
Mailing Address - Street 2:SUITE #520
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102
Mailing Address - Country:US
Mailing Address - Phone:817-529-8151
Mailing Address - Fax:
Practice Address - Street 1:100 E 15TH ST STE 520
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-6566
Practice Address - Country:US
Practice Address - Phone:817-529-8151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15851122300000X
TX325961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist