Provider Demographics
NPI:1538359427
Name:MALCOLM PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:MALCOLM PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDY
Authorized Official - Middle Name:JOE
Authorized Official - Last Name:MALCOLM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-544-0909
Mailing Address - Street 1:163 CADILLAC CT
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-1737
Mailing Address - Country:US
Mailing Address - Phone:815-544-0909
Mailing Address - Fax:815-544-0922
Practice Address - Street 1:163 CADILLAC CT
Practice Address - Street 2:SUITE 3
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-1737
Practice Address - Country:US
Practice Address - Phone:815-544-0909
Practice Address - Fax:815-544-0922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty