Healthcare Provider Details

I. General information

NPI: 1053426536
Provider Name (Legal Business Name): ROBERT WILLIAM MALLOY JR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N 10TH AVE
BOZEMAN MT
59715-3203
US

IV. Provider business mailing address

101 N 10TH AVE
BOZEMAN MT
59715-3203
US

V. Phone/Fax

Practice location:
  • Phone: 406-587-1811
  • Fax: 406-585-0295
Mailing address:
  • Phone: 406-587-1811
  • Fax: 406-585-0295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2043
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: