Provider Demographics
NPI:1609365105
Name:REX C. MALCOM PHARMD DMD, LLC
Entity Type:Organization
Organization Name:REX C. MALCOM PHARMD DMD, LLC
Other - Org Name:ALASKA ADVANCED DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:REX
Authorized Official - Middle Name:
Authorized Official - Last Name:MALCOM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:907-522-3633
Mailing Address - Street 1:6917 OLD SEWARD HWY
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99518-2276
Mailing Address - Country:US
Mailing Address - Phone:907-522-3633
Mailing Address - Fax:
Practice Address - Street 1:6917 OLD SEWARD HWY
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99518-2276
Practice Address - Country:US
Practice Address - Phone:907-522-3633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100531122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1642221Medicaid