Healthcare Provider Details

I. General information

NPI: 1154015097
Provider Name (Legal Business Name): LUKE MADDOX DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1395 CENTER DR # D1-40
GAINESVILLE FL
32610-2005
US

IV. Provider business mailing address

PO BOX 100426
GAINESVILLE FL
32610-0426
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-7643
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2957
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: