Provider Demographics
NPI:1982662821
Name:MALONE, DENNIE L (DMD)
Entity Type:Individual
Prefix:DR
First Name:DENNIE
Middle Name:L
Last Name:MALONE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 NORTHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02324-1249
Mailing Address - Country:US
Mailing Address - Phone:203-788-4052
Mailing Address - Fax:
Practice Address - Street 1:30 NORTHFIELD DR
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02324-1249
Practice Address - Country:US
Practice Address - Phone:203-788-4052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT62191223S0112X
MADN18553601223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002062198Medicaid
T23447Medicare UPIN
190000603Medicare ID - Type Unspecified