Provider Demographics
NPI:1720192008
Name:MALISKA, STAN J (DDS)
Entity Type:Individual
Prefix:DR
First Name:STAN
Middle Name:J
Last Name:MALISKA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 E VILLA MARIA RD
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2549
Mailing Address - Country:US
Mailing Address - Phone:979-776-7166
Mailing Address - Fax:979-776-8284
Practice Address - Street 1:2310 E VILLA MARIA RD
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2549
Practice Address - Country:US
Practice Address - Phone:979-776-7166
Practice Address - Fax:979-776-8284
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX143311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice