Provider Demographics
NPI:1144686627
Name:STECHISHIN, MALLORY A (DDS)
Entity type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:A
Last Name:STECHISHIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72-880 FRED WARING DRIVE
Mailing Address - Street 2:SUITE D-16
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260
Mailing Address - Country:US
Mailing Address - Phone:760-568-2000
Mailing Address - Fax:
Practice Address - Street 1:72-880 FRED WARING DRIVE
Practice Address - Street 2:SUITE D-16
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260
Practice Address - Country:US
Practice Address - Phone:760-568-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35170122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist