=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508977547
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR CHARLES MALKEMUS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 166 COLUMBIA RD
-----------------------------------------------------
City | DORCHESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02121-3411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-445-9880
-----------------------------------------------------
Fax | 617-445-5746
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 166 COLUMBIA RD
-----------------------------------------------------
City | DORCHESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02121-3411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-445-9880
-----------------------------------------------------
Fax | 617-445-5746
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CHARLES M MALKEMUS
-----------------------------------------------------
Credential | DDS, JD
-----------------------------------------------------
Telephone | 617-445-9880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | MA11207
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------