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General NPI Number Information
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NPI Number | 1922498302
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Entity Type | Organization
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Legal Business Name | JERRY B MALLEUS, DDS INC.
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Dates
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Enumeration Date | 01/23/2015
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Last Update Date | 01/23/2015
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Provider Practice Location Address
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Address Line | 125 S BRAND BLVD
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City | SAN FERNANDO
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State | CA
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Zip | 91340-3304
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Country | US
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Telephone | 818-365-6321
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Fax | 818-365-0011
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Provider Business Mailing Address
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Address Line | 125 S BRAND BLVD
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City | SAN FERNANDO
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State | CA
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Zip | 91340-3304
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Country | US
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Telephone | 818-365-6321
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Fax | 818-365-0011
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Authorized Official
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Title or Position | PRES.
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Name | DR. JERRY B MALLEUS
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Credential | DDS
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Telephone | 818-832-5102
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 24826
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License Number State | CA
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