Healthcare Provider Details

I. General information

NPI: 1053234377
Provider Name (Legal Business Name): NICHOLAS T MALLORY DMD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 WEST CENTRAL AVENUE PO BOX 430
EAGAR AZ
85925
US

IV. Provider business mailing address

133 WEST CENTRAL AVENUE PO BOX 430
EAGAR AZ
85925
US

V. Phone/Fax

Practice location:
  • Phone: 928-333-4121
  • Fax:
Mailing address:
  • Phone: 928-333-4121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. NICHOLAS TALBERT MALLORY
Title or Position: OWNER
Credential: DMD
Phone: 928-240-3285