Healthcare Provider Details

I. General information

NPI: 1467437756
Provider Name (Legal Business Name): MALLARD DENTAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 S ADDISON RD STE 101
ADDISON IL
60101-3868
US

IV. Provider business mailing address

33 S ADDISON RD STE 101
ADDISON IL
60101-3868
US

V. Phone/Fax

Practice location:
  • Phone: 630-834-4343
  • Fax: 630-834-6308
Mailing address:
  • Phone: 630-834-4343
  • Fax: 630-834-6308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier103045
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer
# 2
Identifier1001079
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer

VIII. Authorized Official

Name: DR. KONSTADINA ANASTASIA ARALLES
Title or Position: PRESIDENT
Credential: DDS
Phone: 630-834-4343