1538359427 NPI number — MALCOLM PEDIATRIC DENTISTRY

Table of content: DR. SCOTT WALEN M.D., FRCSC (NPI 1023396520)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538359427 NPI number — MALCOLM PEDIATRIC DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MALCOLM PEDIATRIC DENTISTRY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1538359427
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
163 CADILLAC CT
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
BELVIDERE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61008-1737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-544-0909
Provider Business Mailing Address Fax Number:
815-544-0922

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
163 CADILLAC CT
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
BELVIDERE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61008-1737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-544-0909
Provider Business Practice Location Address Fax Number:
815-544-0922
Provider Enumeration Date:
07/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MALCOLM
Authorized Official First Name:
ANDY
Authorized Official Middle Name:
JOE
Authorized Official Title or Position:
PEDIATRIC DENTIST
Authorized Official Telephone Number:
815-544-0909

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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