Provider Demographics
NPI:1477503415
Name:MALONE, DOUGLAS RANDOLPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:RANDOLPH
Last Name:MALONE
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 1:12200 WHITLEY MANOR DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23838-5198
Mailing Address - Country:US
Mailing Address - Phone:804-796-2079
Mailing Address - Fax:
Practice Address - Street 1:9413 HULL STREET ROAD
Practice Address - Street 2:SUITE B-1
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23236
Practice Address - Country:US
Practice Address - Phone:804-745-4550
Practice Address - Fax:804-745-4848
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA53051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice