MEDICARE: DR. DALE LARRIE MALLORY 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	0401005769	VA

General Provider Information

NPI Number	:	1225189665
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DALE LARRIE MALLORY D.D.S.

Provider Business Mailing Address
First Line	:	4867 BAXTER RD
Second Line	:	SUITE 101
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-4469
Country	:	US
Telephone Number	:	757-499-8139
Fax Number	:

Provider Business Practice Location Address
First Line	:	4867 BAXTER RD
Second Line	:	SUITE 101
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-4469
Country	:	US
Telephone Number	:	757-499-8139
Fax Number	:

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

Provider Enumeration Date	:	01/14/2007
Last Update Date	:	07/08/2007

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