Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 2043 | MT |
NPI | 1053426536 |
---|---|
Provider Name | Dr. Robert William Malloy JR. |
First Address | Bozeman, MT 59715-3203 |
Second Address | Bozeman, MT 59715-3203 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/08/2006 |
Last Update Date | 08/07/2007 |