Healthcare Provider Details

I. General information

NPI: 1083747877
Provider Name (Legal Business Name): STEPHEN WILLIAM MALLEY D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 ASHLEY AVE BSB 547
CHARLESTON SC
29425-0001
US

IV. Provider business mailing address

882 SEAFARER WAY
CHARLESTON SC
29412-4918
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-4456
  • Fax:
Mailing address:
  • Phone: 843-795-8850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number2742
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: