Healthcare Provider Details

I. General information

NPI: 1982662821
Provider Name (Legal Business Name): DENNIE L MALONE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 NORTHFIELD DR
BRIDGEWATER MA
02324-1249
US

IV. Provider business mailing address

30 NORTHFIELD DR
BRIDGEWATER MA
02324-1249
US

V. Phone/Fax

Practice location:
  • Phone: 203-788-4052
  • Fax:
Mailing address:
  • Phone: 203-788-4052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6219
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN1855360
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: