Provider Demographics
NPI:1346589405
Name:MALCHOW, HOLLEY GONDER
Entity Type:Individual
Prefix:
First Name:HOLLEY
Middle Name:GONDER
Last Name:MALCHOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HOLLEY
Other - Middle Name:
Other - Last Name:GONDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:7916 PEBBLE BEACH DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95610-7790
Mailing Address - Country:US
Mailing Address - Phone:916-962-0577
Mailing Address - Fax:916-962-0584
Practice Address - Street 1:7916 PEBBLE BEACH DR
Practice Address - Street 2:SUITE 101
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-7790
Practice Address - Country:US
Practice Address - Phone:916-962-0577
Practice Address - Fax:916-962-0584
Is Sole Proprietor?:No
Enumeration Date:2013-02-11
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46807122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist