Provider Demographics
NPI:1962071936
Name:MALLETT, MARK ANDREW (DDS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:MALLETT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-5402
Mailing Address - Country:US
Mailing Address - Phone:501-329-8754
Mailing Address - Fax:
Practice Address - Street 1:550 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-5402
Practice Address - Country:US
Practice Address - Phone:501-329-8754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4524122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist