MEDICARE: DR. KAMELIA KHALIL MALLAK DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	58207	CA
2	122300000X	Dentist	58207	CA

General Provider Information

NPI Number	:	1477797835
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KAMELIA KHALIL MALLAK DDS

Provider Business Mailing Address
First Line	:	3943 E ANAHEIM STREET
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90804
Country	:	US
Telephone Number	:	562-597-4500
Fax Number	:	562-494-7334

Provider Business Practice Location Address
First Line	:	3943 E ANAHEIM STREET
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90804
Country	:	US
Telephone Number	:	562-597-4500
Fax Number	:	562-494-7334

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/28/2009
Last Update Date	:	05/07/2013

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