Provider Demographics
NPI:1497595813
Name:MALLAD, CAMILA ROSE (DDS)
Entity type:Individual
Prefix:
First Name:CAMILA
Middle Name:ROSE
Last Name:MALLAD
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 1:50634 SILVERTON
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-7703
Mailing Address - Country:US
Mailing Address - Phone:313-578-1353
Mailing Address - Fax:
Practice Address - Street 1:29848 FORD RD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-2365
Practice Address - Country:US
Practice Address - Phone:313-578-1353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-31
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016021421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice