Basic Information
| Provider Information | |||||||||
| NPI: | 1245269422 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALIS | ||||||||
| FirstName: | DIDIER-DAVID | ||||||||
| MiddleName: | ANTOINE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D., M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 201088 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772161088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135003500 | ||||||||
| FaxNumber: | 7135005484 | ||||||||
| Practice Location | |||||||||
| Address1: | 6550 FANNIN ST | ||||||||
| Address2: | 2237 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137904600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0106X | F22203 | TX | Y | Dental Providers | Dentist | Oral and Maxillofacial Pathology |
ID Information
| ID | Type | State | Issuer | Description | 89D390 | 01 | TX | BCBS | OTHER |