=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982685160
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD MALEK DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2005
-----------------------------------------------------
Last Update Date | 07/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 587 ELM ST
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06902-5113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-969-0802
-----------------------------------------------------
Fax | 203-326-2990
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 635 MAIN ST ATTN: CREDENTIALING DEPT
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06457-2718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-347-6971
-----------------------------------------------------
Fax | 860-638-6601
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 009446
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------