Provider Demographics
NPI:1942288063
Name:MALEK, MARJAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARJAN
Middle Name:
Last Name:MALEK
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 1:454 LORIDANS DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-3406
Mailing Address - Country:US
Mailing Address - Phone:404-583-3090
Mailing Address - Fax:
Practice Address - Street 1:4720 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:BERKELEY LAKE
Practice Address - State:GA
Practice Address - Zip Code:30071-5735
Practice Address - Country:US
Practice Address - Phone:770-449-1497
Practice Address - Fax:770-449-7992
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012820122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA280388614AMedicaid
GA280388614AMedicaid