Provider Demographics
NPI:1861643017
Name:LEO J. MALIN, D.D.S., S.C.
Entity Type:Organization
Organization Name:LEO J. MALIN, D.D.S., S.C.
Other - Org Name:THE MISSING TOOTH SOLUTION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:J
Authorized Official - Last Name:MALIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-269-0607
Mailing Address - Street 1:3000 RILEY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SPARTA
Mailing Address - State:WI
Mailing Address - Zip Code:54656-6588
Mailing Address - Country:US
Mailing Address - Phone:608-269-0607
Mailing Address - Fax:608-269-0608
Practice Address - Street 1:3000 RILEY RD
Practice Address - Street 2:SUITE A
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-6588
Practice Address - Country:US
Practice Address - Phone:608-269-0607
Practice Address - Fax:608-269-0608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4262261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental