MEDICARE: MALLORY JO NYENHUIS D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	D011313	AZ

General Provider Information

NPI Number	:	1437503364
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALLORY JO NYENHUIS D.D.S.

Provider Business Mailing Address
First Line	:	2756 W HIGHLAND MEADOWS DR
Second Line	:
City	:	WILLIAMS
State	:	AZ
Zip	:	86046-9179
Country	:	US
Telephone Number	:	920-918-0843
Fax Number	:

Provider Business Practice Location Address
First Line	:	223 N SAN FRANCISCO ST STE 104
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-4657
Country	:	US
Telephone Number	:	928-275-1252
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2016
Last Update Date	:	02/13/2025

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