Healthcare Provider Details

I. General information

NPI: 1326538729
Provider Name (Legal Business Name): ANKIT MALHOTRA D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2018
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7310 N VILLA LAKE DR STE B
PEORIA IL
61614
US

IV. Provider business mailing address

5805 N CYPRESS DR APT 3103
PEORIA IL
61615-8408
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-9072
  • Fax:
Mailing address:
  • Phone: 201-823-7448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.031834
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: