Provider Demographics
NPI:1699882837
Name:MALLEY, KEVIN JOSEPH (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JOSEPH
Last Name:MALLEY
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 1:349 W 46TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-3601
Mailing Address - Country:US
Mailing Address - Phone:317-283-6152
Mailing Address - Fax:
Practice Address - Street 1:1900 E MAIN ST
Practice Address - Street 2:VA ILLIANA HCS (160)
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-5100
Practice Address - Country:US
Practice Address - Phone:217-554-4516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16373122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist