Provider Demographics
NPI:1750077103
Name:MALLEY DENTAL, PLLC
Entity type:Organization
Organization Name:MALLEY DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-981-8166
Mailing Address - Street 1:11 LAKELAND CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5006
Mailing Address - Country:US
Mailing Address - Phone:601-981-8166
Mailing Address - Fax:601-362-2164
Practice Address - Street 1:11 LAKELAND CIR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5006
Practice Address - Country:US
Practice Address - Phone:601-981-8166
Practice Address - Fax:601-362-2164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty