Provider Demographics
NPI:1669915898
Name:MALICO, KATHLEEN (RDH,BSDH,OMT)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MALICO
Suffix:
Gender:F
Credentials:RDH,BSDH,OMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 LONE OAK CT
Mailing Address - Street 2:
Mailing Address - City:CENTERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11721-1451
Mailing Address - Country:US
Mailing Address - Phone:631-385-8963
Mailing Address - Fax:
Practice Address - Street 1:15 LONE OAK CT
Practice Address - Street 2:
Practice Address - City:CENTERPORT
Practice Address - State:NY
Practice Address - Zip Code:11721-1451
Practice Address - Country:US
Practice Address - Phone:631-385-8963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-19
Last Update Date:2016-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY159061124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist