Provider Demographics
NPI:1568719151
Name:MALCOLM C. GEORGE, DDS
Entity Type:Organization
Organization Name:MALCOLM C. GEORGE, DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MALCOLM
Authorized Official - Middle Name:C
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:260-726-4710
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010495122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty