Stephen C Mallow, DDS
Individual provider
Active NPI
Dentist · Upper Tract, WV
NPI 1720185523 · NPPES record last updated Aug 19, 2015
Key facts
- NPI
- 1720185523
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 2529 (WV)
- Practice address
- 8791 Petersbug Pike
Upper Tract, WV 26866-8016
- Phone
- (304) 358-7200
- Fax
- (304) 358-7284
- NPI assigned
- Sep 20, 2006
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in WV
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|
| I20160329001066 |
WV |
Order and Referring Only - Dentist
Practitioner - Dentist |
9436456936 |
|
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|
| 2529 | WV | MD | Dentist |
Practice roles
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|
| Dentist |
122300000X |
2529 |
WV |
Yes |
Addresses
Primary practice location
8791 Petersbug Pike
Upper Tract, WV 26866-8016
Mailing address
8791 Petersbug Pike
Upper Tract, WV 26866-8016
Phone (304) 358-7200
Other identifiers
| Identifier | Type | State | Issuer |
|---|
| 0136526000 | Medicaid | WV | |