Healthcare Provider Details

I. General information

NPI: 1912088915
Provider Name (Legal Business Name): DR. MARK JAMES MADDEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 ELM AVE
DELANO MN
55313-9183
US

IV. Provider business mailing address

707 ELM AE
DELANO MN
55313-9183
US

V. Phone/Fax

Practice location:
  • Phone: 763-972-2800
  • Fax: 763-972-9036
Mailing address:
  • Phone: 763-972-2800
  • Fax: 763-972-9064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10222
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: