Healthcare Provider Details

I. General information

NPI: 1770617615
Provider Name (Legal Business Name): RANDALL LYNN MALAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1642 E HERNDON AVE SUITE 105
FRESNO CA
93720-3377
US

IV. Provider business mailing address

1642 E HERNDON AVE SUITE 105
FRESNO CA
93720-3377
US

V. Phone/Fax

Practice location:
  • Phone: 559-261-2055
  • Fax:
Mailing address:
  • Phone: 559-261-2055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number36260
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: