Provider Demographics
NPI:1942314745
Name:MALCOLM, TERRY LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:LEE
Last Name:MALCOLM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:1910 CHASE STREET
Mailing Address - City:FALLS CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68355-0188
Mailing Address - Country:US
Mailing Address - Phone:402-245-4636
Mailing Address - Fax:402-245-3325
Practice Address - Street 1:1910 CHASE ST
Practice Address - Street 2:
Practice Address - City:FALLS CITY
Practice Address - State:NE
Practice Address - Zip Code:68355-2021
Practice Address - Country:US
Practice Address - Phone:402-245-4636
Practice Address - Fax:402-245-3325
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE57791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice