1275572737 NPI number — JOHN CHARLES MALLOY DMD

Table of content: JOHN CHARLES MALLOY DMD (NPI 1275572737)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275572737 NPI number — JOHN CHARLES MALLOY DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALLOY
Provider First Name:
JOHN
Provider Middle Name:
CHARLES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275572737
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
317 NORTH ELEVENTH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNBURY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-286-1631
Provider Business Mailing Address Fax Number:
570-286-0595

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 FARLEY CIRCLE
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
LEWISBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-524-2828
Provider Business Practice Location Address Fax Number:
570-524-9199
Provider Enumeration Date:
06/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  DS030741L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223S0112X , with the licence number: DA031566 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 50017985 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 83988 . This is a "GEISINGER HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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