Provider Demographics
NPI:1720185523
Name:MALLOW, STEPHEN C (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:C
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 PETERSBUG 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:304-358-7200
Mailing Address - Fax:304-358-7284
Practice Address - Street 1:8791 PETERSBUG PIKE
Practice Address - Street 2:
Practice Address - City:UPPER TRACT
Practice Address - State:WV
Practice Address - Zip Code:26866-8016
Practice Address - Country:US
Practice Address - Phone:304-358-7200
Practice Address - Fax:304-358-7284
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2529122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0136526000Medicaid