Provider Demographics
NPI:1154655959
Name:MALCOLM, JOAN S (DDS)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:S
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 INDEPENDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-1094
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:402 INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081-1094
Practice Address - Country:US
Practice Address - Phone:856-875-8775
Practice Address - Fax:856-875-8717
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-25
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI019757001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice