Healthcare Provider Details

I. General information

NPI: 1306897152
Provider Name (Legal Business Name): DAVID J MALOLEY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 11/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WEST BEAVER CREEK BLVD SUITE 232
AVON CO
81620
US

IV. Provider business mailing address

PO BOX 2916
AVON CO
81620-2900
US

V. Phone/Fax

Practice location:
  • Phone: 979-949-3331
  • Fax:
Mailing address:
  • Phone: 979-949-3331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number6382
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8514
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10014
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: