=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114095478
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MORAD R MALAKI DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3608 W CAMELBACK RD
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-544-2480
-----------------------------------------------------
Fax | 602-242-4267
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1739 E BROADWAY RD STE #171
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-235-9074
-----------------------------------------------------
Fax | 602-242-4267
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D5701
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------