Provider Demographics
NPI:1669906301
Name:PRUDEN, MALLORY GAYLE (DDS)
Entity type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:GAYLE
Last Name:PRUDEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MALLORY
Other - Middle Name:GAYLE
Other - Last Name:DEBNAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:135 LANDREAUX DR
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-1509
Mailing Address - Country:US
Mailing Address - Phone:318-355-8166
Mailing Address - Fax:
Practice Address - Street 1:135 LANDREAUX DR
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-1509
Practice Address - Country:US
Practice Address - Phone:318-355-8166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA67731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice