Healthcare Provider Details

I. General information

NPI: 1154981371
Provider Name (Legal Business Name): BEVIN K MALLE DDS PA II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9817 SUZANNE CT. SUITE B
WAXHAW NC
28173-8848
US

IV. Provider business mailing address

3900 WINDWOOD CIRCLE
CHARLOTTE NC
28226-7928
US

V. Phone/Fax

Practice location:
  • Phone: 980-339-8730
  • Fax: 704-790-0593
Mailing address:
  • Phone: 704-790-0590
  • Fax: 704-790-0593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: BEVIN KILEY MALLEY
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 704-883-4624