Provider Demographics
NPI:1497061766
Name:MALKOVICH, ROSE A (CLDA)
Entity Type:Individual
Prefix:MISS
First Name:ROSE
Middle Name:A
Last Name:MALKOVICH
Suffix:
Gender:F
Credentials:CLDA
Other - Prefix:MRS
Other - First Name:ROSE
Other - Middle Name:A
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3657 MINNEHAHA AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-2628
Mailing Address - Country:US
Mailing Address - Phone:612-721-1689
Mailing Address - Fax:
Practice Address - Street 1:3657 MINNEHAHA AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-2628
Practice Address - Country:US
Practice Address - Phone:612-721-1689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA4520126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant