Provider Demographics
NPI:1538158043
Name:MALLYA, SANJAY M (BDS)
Entity type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:M
Last Name:MALLYA
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Gender:M
Credentials:BDS
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Mailing Address - Street 1:P.O. BOX 951668
Mailing Address - Street 2:CHS 10-165
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-1668
Mailing Address - Country:US
Mailing Address - Phone:860-679-2453
Mailing Address - Fax:860-679-2756
Practice Address - Street 1:10833 LE CONTE AVE
Practice Address - Street 2:CHS 10-165
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1668
Practice Address - Country:US
Practice Address - Phone:310-825-5634
Practice Address - Fax:310-206-2748
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2010-03-02
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Provider Licenses
StateLicense IDTaxonomies
CT90261223X0008X
CASP-2511223X0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0008XDental ProvidersDentistOral and Maxillofacial Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004010807Medicaid