=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366014383
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADDISON ANNE MCCONNAUGHHAY DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2021
-----------------------------------------------------
Last Update Date | 10/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1579 N DYSART RD STE F
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85392-1221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-935-9873
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 W VERNON AVE UNIT 606
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85003-0011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-705-3018
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 7730
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | D012194
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------