Healthcare Provider Details

I. General information

NPI: 1962516781
Provider Name (Legal Business Name): TERRY L. MALCOLM, DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 06/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 CHASE ST
FALLS CITY NE
68355-2021
US

IV. Provider business mailing address

PO BOX 188 1910 CHASE STREET
FALLS CITY NE
68355-0188
US

V. Phone/Fax

Practice location:
  • Phone: 402-245-4636
  • Fax: 402-245-3325
Mailing address:
  • Phone: 402-245-4636
  • Fax: 402-245-3325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number5779
License Number StateNE

VIII. Authorized Official

Name: DR. TERRY MALCOLM
Title or Position: OWNER/PRESIDENT
Credential: DDS
Phone: 402-245-4636