Provider Demographics
NPI:1710547039
Name:MALLOW, CHRISTOPHER STEPHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:STEPHEN
Last Name:MALLOW
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 1:8791 PETERSBURG PIKE
Mailing Address - Street 2:
Mailing Address - City:UPPER TRACT
Mailing Address - State:WV
Mailing Address - Zip Code:26866-8016
Mailing Address - Country:US
Mailing Address - Phone:304-358-2887
Mailing Address - Fax:
Practice Address - Street 1:9030 PETERSBURG PIKE
Practice Address - Street 2:
Practice Address - City:UPPER TRACT
Practice Address - State:WV
Practice Address - Zip Code:26866-8014
Practice Address - Country:US
Practice Address - Phone:304-358-7284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV44051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice