Healthcare Provider Details

I. General information

NPI: 1114623170
Provider Name (Legal Business Name): DIVYA MALIK DENTIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2023
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 PROSPECT ST
READING PA
19606-2897
US

IV. Provider business mailing address

902 W HAMILTON ST APT 808
ALLENTOWN PA
18101-1178
US

V. Phone/Fax

Practice location:
  • Phone: 610-708-2922
  • Fax:
Mailing address:
  • Phone: 716-239-3011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS044187
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number13852
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13852
License Number StateCT
# 4
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: