Provider Demographics
NPI:1942438486
Name:MALLYA, JOHN RATNAKER (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RATNAKER
Last Name:MALLYA
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 1:2001 RICHARD DR
Mailing Address - Street 2:
Mailing Address - City:BROOMALL
Mailing Address - State:PA
Mailing Address - Zip Code:19008-2742
Mailing Address - Country:US
Mailing Address - Phone:484-461-7169
Mailing Address - Fax:
Practice Address - Street 1:579TH DENTAL SQUADRON
Practice Address - Street 2:BOLLING AFB
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:20332
Practice Address - Country:US
Practice Address - Phone:484-266-9537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS037936122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist