Healthcare Provider Details

I. General information

NPI: 1083688865
Provider Name (Legal Business Name): SUSAN REGINA MALLERY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 03/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W 12TH AVE COLLEGE OF DENTISTRY OHIO STATE UNIVERSITY
COLUMBUS OH
43210-1267
US

IV. Provider business mailing address

305 W 12TH AVE COLLEGE OF DENTISTRY OHIO STATE UNIVERSITY
COLUMBUS OH
43210-1267
US

V. Phone/Fax

Practice location:
  • Phone: 614-292-5892
  • Fax: 614-292-9384
Mailing address:
  • Phone: 614-292-5892
  • Fax: 614-292-9384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number30016966
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: