Provider Demographics
NPI:1942717228
Name:MALLERNEE FAMILY DENTAL PLLC
Entity Type:Organization
Organization Name:MALLERNEE FAMILY DENTAL PLLC
Other - Org Name:RESTORATION DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KYE
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:MALLERNEE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-619-1059
Mailing Address - Street 1:9820 BRAUN RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254-9656
Mailing Address - Country:US
Mailing Address - Phone:217-619-1059
Mailing Address - Fax:
Practice Address - Street 1:9820 BRAUN RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78254-9656
Practice Address - Country:US
Practice Address - Phone:217-619-1059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX313281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty