Provider Demographics
NPI:1487433256
Name:KONOP-DEFREITAS, MAALIK
Entity type:Individual
Prefix:
First Name:MAALIK
Middle Name:
Last Name:KONOP-DEFREITAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11131 ROSE AVE APT 9
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-6019
Mailing Address - Country:US
Mailing Address - Phone:651-470-5681
Mailing Address - Fax:
Practice Address - Street 1:4425 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-3629
Practice Address - Country:US
Practice Address - Phone:323-908-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1095081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice