Healthcare Provider Details

I. General information

NPI: 1942438486
Provider Name (Legal Business Name): JOHN RATNAKER MALLYA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2009
Last Update Date: 06/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

579TH DENTAL SQUADRON BOLLING AFB
APO AA
20332
US

IV. Provider business mailing address

2001 RICHARD DR
BROOMALL PA
19008-2742
US

V. Phone/Fax

Practice location:
  • Phone: 484-266-9537
  • Fax:
Mailing address:
  • Phone: 484-461-7169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS037936
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: