Healthcare Provider Details

I. General information

NPI: 1891535258
Provider Name (Legal Business Name): MADELINE ANNE VAJI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2024
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817-B LOOP 250 FRONTAGE RD
MIDLAND TX
79705
US

IV. Provider business mailing address

11710 PINEHURST DR
CHARDON OH
44024-7400
US

V. Phone/Fax

Practice location:
  • Phone: 432-694-4800
  • Fax:
Mailing address:
  • Phone: 440-867-4343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number40543
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: