Provider Demographics
NPI:1124047394
Name:MUSGRAVE, MALCOLM E (DDS)
Entity type:Individual
Prefix:
First Name:MALCOLM
Middle Name:E
Last Name:MUSGRAVE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 N TUCSON BLVD STE 30
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-3408
Mailing Address - Country:US
Mailing Address - Phone:520-326-9693
Mailing Address - Fax:520-918-9696
Practice Address - Street 1:1601 N TUCSON BLVD STE 30
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-3408
Practice Address - Country:US
Practice Address - Phone:520-326-9693
Practice Address - Fax:520-918-9696
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ35661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice