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General NPI Number Information
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NPI Number | 1568719151
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Entity Type | Organization
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Legal Business Name | MALCOLM C. GEORGE, DDS
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Dates
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Enumeration Date | 08/14/2012
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Last Update Date | 08/14/2012
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Provider Practice Location Address
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Address Line | 112 N SHIP ST
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City | PORTLAND
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State | IN
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Zip | 47371-1844
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Country | US
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Telephone | 260-726-4710
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Fax | 260-726-7051
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Provider Business Mailing Address
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Address Line | 112 N SHIP ST
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City | PORTLAND
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State | IN
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Zip | 47371-1844
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Country | US
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Telephone | 260-726-4710
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Fax | 260-726-7051
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Authorized Official
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Title or Position | DENTIST
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Name | MALCOLM C. GEORGE
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Credential | DDS
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Telephone | 260-726-4710
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 12010495
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License Number State | IN
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