Provider Demographics
NPI:1033207089
Name:MALCOLM, ANDY J (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANDY
Middle Name:J
Last Name:MALCOLM
Suffix:
Gender:M
Credentials:DDS
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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
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry