Healthcare Provider Details

I. General information

NPI: 1538158043
Provider Name (Legal Business Name): SANJAY M MALLYA B.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 03/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10833 LE CONTE AVE CHS 10-165
LOS ANGELES CA
90095-1668
US

IV. Provider business mailing address

P.O. BOX 951668 CHS 10-165
LOS ANGELES CA
90095-1668
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-5634
  • Fax: 310-206-2748
Mailing address:
  • Phone: 860-679-2453
  • Fax: 860-679-2756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number9026
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License NumberSP-251
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: