Healthcare Provider Details

I. General information

NPI: 1003602186
Provider Name (Legal Business Name): MALINDA GRACE ROYCE RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2025
Last Update Date: 04/16/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5883 BLACK DIAMOND HWY
GARY WV
24836
US

IV. Provider business mailing address

664 LITTLESBURG RD
BLUEFIELD WV
24701-6685
US

V. Phone/Fax

Practice location:
  • Phone: 304-448-2101
  • Fax:
Mailing address:
  • Phone: 304-320-3050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2439
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: