MEDICARE: DR. MARC P MALLORY D.D.S., PLLC

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	14433	MI

General Provider Information

NPI Number	:	1588643134
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARC P MALLORY D.D.S., PLLC

Provider Business Mailing Address
First Line	:	107 E. WASHTENAW
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48933-1822
Country	:	US
Telephone Number	:	517-487-5666
Fax Number	:	517-267-0938

Provider Business Practice Location Address
First Line	:	107 E. WASHTENAW
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48933-1822
Country	:	US
Telephone Number	:	517-487-5666
Fax Number	:	517-267-0938

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

Provider Enumeration Date	:	01/12/2006
Last Update Date	:	10/26/2016

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