Provider Demographics
NPI:1356732309
Name:FIFTH STREET DENTAL CARE PLLC
Entity type:Organization
Organization Name:FIFTH STREET DENTAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DONI
Authorized Official - Middle Name:R
Authorized Official - Last Name:MALLIA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-426-2220
Mailing Address - Street 1:8048 5TH ST
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MI
Mailing Address - Zip Code:48130-1033
Mailing Address - Country:US
Mailing Address - Phone:734-426-2220
Mailing Address - Fax:734-426-4480
Practice Address - Street 1:8048 5TH ST
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MI
Practice Address - Zip Code:48130-1033
Practice Address - Country:US
Practice Address - Phone:734-426-2220
Practice Address - Fax:734-426-4480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901017984261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental