Provider Demographics
NPI:1114623170
Name:MALIK, DIVYA (DENTIST)
Entity type:Individual
Prefix:
First Name:DIVYA
Middle Name:
Last Name:MALIK
Suffix:
Gender:F
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 PULASKI AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-4111
Mailing Address - Country:US
Mailing Address - Phone:716-239-3011
Mailing Address - Fax:
Practice Address - Street 1:165 MILLER ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-4482
Practice Address - Country:US
Practice Address - Phone:860-388-4433
Practice Address - Fax:860-388-4434
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT13852122300000X, 1223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program