Provider Demographics
NPI:1063521805
Name:MALVIN, JACK LEE (DMD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:LEE
Last Name:MALVIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 S HIGHLAND AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15206-3937
Mailing Address - Country:US
Mailing Address - Phone:412-661-7316
Mailing Address - Fax:412-661-5903
Practice Address - Street 1:242 S HIGHLAND AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15206-3937
Practice Address - Country:US
Practice Address - Phone:412-661-7316
Practice Address - Fax:412-661-5903
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA020641-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice