Provider Demographics
NPI:1467675157
Name:GEORGE, MALCOLM CHRISTIAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:CHRISTIAN
Last Name:GEORGE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 N SHIP ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47371-1844
Mailing Address - Country:US
Mailing Address - Phone:260-726-4710
Mailing Address - Fax:260-726-7051
Practice Address - Street 1:112 N SHIP ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-1844
Practice Address - Country:US
Practice Address - Phone:260-726-4710
Practice Address - Fax:260-726-7051
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010495122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist