Healthcare Provider Details

I. General information

NPI: 1194201996
Provider Name (Legal Business Name): LAILA MALAKI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2018
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1969 W OGDEN AVE
CHICAGO IL
60612-3765
US

IV. Provider business mailing address

2158 183RD ST
HOMEWOOD IL
60430-3238
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-3202
  • Fax:
Mailing address:
  • Phone: 630-864-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number019-031718
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019.031718
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: