Healthcare Provider Details

I. General information

NPI: 1477797835
Provider Name (Legal Business Name): KAMELIA KHALIL MALLAK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAMELIA S. KHALIL

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 05/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3943 E ANAHEIM STREET
LONG BEACH CA
90804
US

IV. Provider business mailing address

3943 E ANAHEIM STREET
LONG BEACH CA
90804
US

V. Phone/Fax

Practice location:
  • Phone: 562-597-4500
  • Fax: 562-494-7334
Mailing address:
  • Phone: 562-597-4500
  • Fax: 562-494-7334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number58207
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number58207
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: