Healthcare Provider Details

I. General information

NPI: 1104276088
Provider Name (Legal Business Name): ELIZAVETA MALININA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 KNOLLCROFT RD
LYONS NJ
07939-5001
US

IV. Provider business mailing address

36 HAWTHORNE PL APT 2A
MONTCLAIR NJ
07042-3243
US

V. Phone/Fax

Practice location:
  • Phone: 908-647-0180
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1857677
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: