Provider Demographics
NPI:1528213121
Name:MALCOM, ANDREA LYNNE (DH)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYNNE
Last Name:MALCOM
Suffix:
Gender:F
Credentials:DH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4920 S 30TH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68107-1590
Mailing Address - Country:US
Mailing Address - Phone:402-734-4110
Mailing Address - Fax:402-952-1020
Practice Address - Street 1:4920 SOUTH 30TH STREET
Practice Address - Street 2:SUITE 103
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68107-1656
Practice Address - Country:US
Practice Address - Phone:402-734-4110
Practice Address - Fax:402-952-1020
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2000124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist