Provider Demographics
NPI:1447811310
Name:AL-GROUZ, MALIK (DMD)
Entity type:Individual
Prefix:DR
First Name:MALIK
Middle Name:
Last Name:AL-GROUZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 W HURON ST UNIT 1405
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-5980
Mailing Address - Country:US
Mailing Address - Phone:708-638-6135
Mailing Address - Fax:
Practice Address - Street 1:1009 N H ST STE P
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-8141
Practice Address - Country:US
Practice Address - Phone:805-242-4044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103832122300000X
IL019.034519122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist