Healthcare Provider Details

I. General information

NPI: 1770134934
Provider Name (Legal Business Name): QURATUL AIN MALIK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2019
Last Update Date: 09/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 PROSPECT AVE STE 304
HACKENSACK NJ
07601-2570
US

IV. Provider business mailing address

40 WATERSIDE PLZ APT 7G
NEW YORK NY
10010-2640
US

V. Phone/Fax

Practice location:
  • Phone: 201-425-9580
  • Fax:
Mailing address:
  • Phone: 714-906-7773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number22DI02776000
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: