Healthcare Provider Details

I. General information

NPI: 1619043510
Provider Name (Legal Business Name): LEO J MALIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 12/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 3RD ST S
LA CROSSE WI
54601-4049
US

IV. Provider business mailing address

305 3RD ST S
LA CROSSE WI
54601-4049
US

V. Phone/Fax

Practice location:
  • Phone: 608-498-4660
  • Fax: 608-260-7706
Mailing address:
  • Phone: 608-498-4660
  • Fax: 608-260-7706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4262
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4262
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: