Provider Demographics
NPI:1386252328
Name:MALONEY, ELIZABETH RYANN
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:RYANN
Last Name:MALONEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:RYANN
Other - Last Name:GILLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18650 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-3700
Mailing Address - Country:US
Mailing Address - Phone:708-798-4424
Mailing Address - Fax:
Practice Address - Street 1:18650 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-3700
Practice Address - Country:US
Practice Address - Phone:630-750-1499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032710122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty