MEDICARE: DR. SYLVESTER B MALCOM D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	15814	MD
2	1223G0001X	General Practice Dentistry	DN122625	GA

General Provider Information

NPI Number	:	1124487590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SYLVESTER B MALCOM D.D.S.

Provider Business Mailing Address
First Line	:	859 JIM DAWS RD
Second Line	:
City	:	MONROE
State	:	GA
Zip	:	30656-4863
Country	:	US
Telephone Number	:	678-559-5891
Fax Number	:

Provider Business Practice Location Address
First Line	:	1002 POINTE SOUTH PKWY
Second Line	:
City	:	JONESBORO
State	:	GA
Zip	:	30238-4324
Country	:	US
Telephone Number	:	678-559-5891
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/15/2016
Last Update Date	:	09/06/2022

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