Healthcare Provider Details

I. General information

NPI: 1629134317
Provider Name (Legal Business Name): MALINDA MAYNARD HUSSON DDS, MSD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 03/11/2022
Certification Date: 03/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 MACCORKLE AVE SE STE C
CHARLESTON WV
25304-1835
US

IV. Provider business mailing address

4502 MACCORKLE AVE SE STE C
CHARLESTON WV
25304-1835
US

V. Phone/Fax

Practice location:
  • Phone: 304-926-9260
  • Fax: 304-926-9266
Mailing address:
  • Phone: 304-926-9260
  • Fax: 304-926-9266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401410708
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number3557
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number3557
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0401410708
License Number StateVA
# 5
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3557
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: