Provider Demographics
NPI:1801184270
Name:ROXANNE MALONE
Entity Type:Organization
Organization Name:ROXANNE MALONE
Other - Org Name:ROXANNE MALONE DDS, PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:C
Authorized Official - Last Name:GROOTHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-589-6667
Mailing Address - Street 1:1511 US HIGHWAY 1
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-1611
Mailing Address - Country:US
Mailing Address - Phone:772-589-6667
Mailing Address - Fax:772-581-2968
Practice Address - Street 1:1511 US HIGHWAY 1
Practice Address - Street 2:SUITE 201
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-1611
Practice Address - Country:US
Practice Address - Phone:772-589-6667
Practice Address - Fax:772-581-2968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN13897122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty