Provider Demographics
NPI:1457894149
Name:MALAN DENTAL PC
Entity Type:Organization
Organization Name:MALAN DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MALAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-394-3767
Mailing Address - Street 1:3860 JACKSON AVE
Mailing Address - Street 2:STE 5
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-1956
Mailing Address - Country:US
Mailing Address - Phone:801-394-3767
Mailing Address - Fax:
Practice Address - Street 1:3860 JACKSON AVE
Practice Address - Street 2:STE 5
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1956
Practice Address - Country:US
Practice Address - Phone:801-394-3767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty