Provider Demographics
NPI:1275572737
Name:MALLOY, JOHN CHARLES (DMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
Last Name:MALLOY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 NORTH ELEVENTH STREET
Mailing Address - Street 2:
Mailing Address - City:SUNBURY
Mailing Address - State:PA
Mailing Address - Zip Code:17801
Mailing Address - Country:US
Mailing Address - Phone:570-286-1631
Mailing Address - Fax:570-286-0595
Practice Address - Street 1:115 FARLEY CIRCLE
Practice Address - Street 2:SUITE 203
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837
Practice Address - Country:US
Practice Address - Phone:570-524-2828
Practice Address - Fax:570-524-9199
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS030741L1223S0112X
PADA0315661223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50017985OtherCAPITAL BLUE CROSS
PA83988OtherGEISINGER HEALTH PLAN
PA83988OtherGEISINGER HEALTH PLAN
U97139Medicare UPIN