Provider Demographics
NPI:1750066767
Name:IZMALKOVA, LIANA GENNADYEVNA (DDS)
Entity type:Individual
Prefix:
First Name:LIANA
Middle Name:GENNADYEVNA
Last Name:IZMALKOVA
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 1:22717 AGAVE GROVE DR
Mailing Address - Street 2:
Mailing Address - City:LAGO VISTA
Mailing Address - State:TX
Mailing Address - Zip Code:78645-2304
Mailing Address - Country:US
Mailing Address - Phone:757-620-1525
Mailing Address - Fax:
Practice Address - Street 1:1100 LOWES BLVD STE 100
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-5491
Practice Address - Country:US
Practice Address - Phone:254-382-8735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX395961223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist