Healthcare Provider Details

I. General information

NPI: 1861697112
Provider Name (Legal Business Name): RONALD CRAIG MADDOX D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W COVINA BLVD SUITE 110
SAN DIMAS CA
91773-3205
US

IV. Provider business mailing address

7 SCOTIA SEA
NEWPORT COAST CA
92657-2104
US

V. Phone/Fax

Practice location:
  • Phone: 909-394-7710
  • Fax: 909-394-7703
Mailing address:
  • Phone: 949-636-1911
  • Fax: 949-497-9398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number32353
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: