Provider Demographics
NPI:1154981371
Name:BEVIN K MALLE DDS PA II
Entity type:Organization
Organization Name:BEVIN K MALLE DDS PA II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BEVIN
Authorized Official - Middle Name:KILEY
Authorized Official - Last Name:MALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-883-4624
Mailing Address - Street 1:3900 WINDWOOD CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-7928
Mailing Address - Country:US
Mailing Address - Phone:704-790-0590
Mailing Address - Fax:704-790-0593
Practice Address - Street 1:9817 SUZANNE CT.
Practice Address - Street 2:SUITE B
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-8848
Practice Address - Country:US
Practice Address - Phone:980-339-8730
Practice Address - Fax:704-790-0593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty