Healthcare Provider Details

I. General information

NPI: 1770554560
Provider Name (Legal Business Name): WILLIAM FRANCIS MADDUX D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 05/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 E 10TH ST
ROLLA MO
65401-4603
US

IV. Provider business mailing address

13315 COUNTY ROAD 5110
ROLLA MO
65401-5811
US

V. Phone/Fax

Practice location:
  • Phone: 573-364-1821
  • Fax:
Mailing address:
  • Phone: 580-574-0741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number015200
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: