=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861643017
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEO J. MALIN, D.D.S., S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2008
-----------------------------------------------------
Last Update Date | 10/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3000 RILEY RD SUITE A
-----------------------------------------------------
City | SPARTA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54656-6588
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-269-0607
-----------------------------------------------------
Fax | 608-269-0608
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3000 RILEY RD SUITE A
-----------------------------------------------------
City | SPARTA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54656-6588
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-269-0607
-----------------------------------------------------
Fax | 608-269-0608
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LEO J. MALIN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 608-269-0607
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 4262
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------