Provider Demographics
NPI:1427038231
Name:MALLOY, CHRISTOPHER EARL (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:EARL
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 1:1071 HIWAY 95
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-5566
Mailing Address - Country:US
Mailing Address - Phone:208-549-0838
Mailing Address - Fax:208-549-2296
Practice Address - Street 1:1067 HWY 95
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672
Practice Address - Country:US
Practice Address - Phone:208-549-0838
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD18931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0019569Medicaid