Healthcare Provider Details

I. General information

NPI: 1164220075
Provider Name (Legal Business Name): SAMUEL MADDEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2025
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MISSILE AVE
MINOT AFB ND
58705-5003
US

IV. Provider business mailing address

3501 HARBISON DR UNIT 1903
VACAVILLE CA
95687-3938
US

V. Phone/Fax

Practice location:
  • Phone: 701-723-5565
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD15349
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: