1023326287 NPI number — BEVIN K MALLEY DDS PA

Table of content: (NPI 1023326287)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023326287 NPI number — BEVIN K MALLEY DDS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEVIN K MALLEY DDS PA
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:
6
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:
1023326287
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6918 GARDEN TERRACE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28210-2706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-790-0590
Provider Business Mailing Address Fax Number:
704-790-0593

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6918 GARDEN TERRACE CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28210-2706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-790-0590
Provider Business Practice Location Address Fax Number:
704-790-0593
Provider Enumeration Date:
09/21/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MALLEY
Authorized Official First Name:
BEVIN
Authorized Official Middle Name:
KILEY
Authorized Official Title or Position:
PEDIATRIC DENTIST
Authorized Official Telephone Number:
704-790-0590

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  8238 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5906.301 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1356359004 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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