MEDICARE: CHARLES BRENT MALLIN 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	1223G0001X	General Practice Dentistry	11962	MO

General Provider Information

NPI Number	:	1750573960
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES BRENT MALLIN D.D.S.

Provider Business Mailing Address
First Line	:	8000 BONHOMME AVE STE 401
Second Line	:	SUITE 401
City	:	CLAYTON
State	:	MO
Zip	:	63105-3515
Country	:	US
Telephone Number	:	314-727-2288
Fax Number	:	314-727-2285

Provider Business Practice Location Address
First Line	:	8000 BONHOMME AVE STE 401
Second Line	:	SUITE 401
City	:	CLAYTON
State	:	MO
Zip	:	63105-3515
Country	:	US
Telephone Number	:	314-727-2288
Fax Number	:	314-727-2285

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

Provider Enumeration Date	:	08/11/2007
Last Update Date	:	08/11/2007

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