Provider Demographics
NPI:1083395081
Name:STEPHEN C MALLOW DBA UPPER TRACT DENTAL
Entity Type:Organization
Organization Name:STEPHEN C MALLOW DBA UPPER TRACT DENTAL
Other - Org Name:UPPER TRACT DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MALLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-358-8152
Mailing Address - Street 1:8791 PETERSBURG PIKE
Mailing Address - Street 2:
Mailing Address - City:UPPER TRACT
Mailing Address - State:WV
Mailing Address - Zip Code:26866-8016
Mailing Address - Country:US
Mailing Address - Phone:304-358-8152
Mailing Address - Fax:
Practice Address - Street 1:9030 PETERSBURG PIKE
Practice Address - Street 2:
Practice Address - City:UPPER TRACT
Practice Address - State:WV
Practice Address - Zip Code:26866-8014
Practice Address - Country:US
Practice Address - Phone:304-358-7200
Practice Address - Fax:304-358-7284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-31
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty