Basic Information
| Provider Information | |||||||||
| NPI: | 1639799463 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALMSTROM | ||||||||
| FirstName: | NIKLAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 506 6TH ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112153609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187803000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6481 OLD BEULAH ST | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223153723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039976073 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2020 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 0401418079 | VA | Y | Dental Providers | Dentist |
No ID Information.