Provider Demographics
NPI:1366550881
Name:MALMSTROM, HANS (DDS)
Entity type:Individual
Prefix:
First Name:HANS
Middle Name:
Last Name:MALMSTROM
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 1:625 ELMWOOD AVE
Mailing Address - Street 2:BOX 683
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-2913
Mailing Address - Country:US
Mailing Address - Phone:585-275-5087
Mailing Address - Fax:585-276-0293
Practice Address - Street 1:625 ELMWOOD AVE
Practice Address - Street 2:BOX 683
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-2913
Practice Address - Country:US
Practice Address - Phone:585-275-5087
Practice Address - Fax:585-276-0293
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0440971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
7165OtherBLUE SHIELD GROUP NUMBER