Basic Information
| Provider Information | |||||||||
| NPI: | 1528213121 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALCOM | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DH | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4920 S 30TH ST | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681071590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027344110 | ||||||||
| FaxNumber: | 4029521020 | ||||||||
| Practice Location | |||||||||
| Address1: | 4920 SOUTH 30TH STREET | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681071656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027344110 | ||||||||
| FaxNumber: | 4029521020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2008 | ||||||||
| LastUpdateDate: | 09/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 2000 | NE | Y | Dental Providers | Dental Hygienist |
No ID Information.