Healthcare Provider Details

I. General information

NPI: 1245789122
Provider Name (Legal Business Name): MADDEN FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 10/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3358 MAIN ST
MEXICO NY
13114-3002
US

IV. Provider business mailing address

3358 MAIN ST
MEXICO NY
13114-3002
US

V. Phone/Fax

Practice location:
  • Phone: 315-963-3412
  • Fax:
Mailing address:
  • Phone: 315-963-3412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number034937
License Number StateNY

VIII. Authorized Official

Name: THOMAS MADDEN
Title or Position: DR/OWNER
Credential:
Phone: 315-963-3412