Healthcare Provider Details

I. General information

NPI: 1740240878
Provider Name (Legal Business Name): JACQUELINE MICHELLE MALONE DMD, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 12/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3005 ROYAL BLVD S SUITE 200
ALPHARETTA GA
30022-1409
US

IV. Provider business mailing address

3005 ROYAL BLVD S SUITE 200
ALPHARETTA GA
30022-1409
US

V. Phone/Fax

Practice location:
  • Phone: 770-619-1776
  • Fax: 770-619-1730
Mailing address:
  • Phone: 770-619-1776
  • Fax: 770-619-1730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN011560
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: