Provider Demographics
NPI:1790906105
Name:MALONSO, ROBERT (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:MALONSO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4095 EVERGREEN VILLAGE SQ STE 120
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95135-1747
Mailing Address - Country:US
Mailing Address - Phone:408-528-0530
Mailing Address - Fax:408-528-0533
Practice Address - Street 1:4095 EVERGREEN VILLAGE SQ STE 120
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95135-1747
Practice Address - Country:US
Practice Address - Phone:408-528-0530
Practice Address - Fax:408-528-0533
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49587122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223G0001XDental ProvidersDentistGeneral Practice