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General NPI Number Information
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NPI Number | 1821959131
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Entity Type | Organization
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Legal Business Name | COUNTRY CLUB DENTAL PLLC
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Dates
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Enumeration Date | 11/18/2025
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Last Update Date | 11/18/2025
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Provider Practice Location Address
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Address Line | 1520 COUNTRY CLUB RD
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City | FAIRMONT
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State | WV
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Zip | 26554-1353
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Country | US
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Telephone | 304-363-9160
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Fax |
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Provider Business Mailing Address
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Address Line | 80 GARDEN CIR
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City | BRIDGEPORT
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State | WV
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Zip | 26330-1367
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Country | US
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Telephone | 304-672-9994
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. NADIA MARDMOMEN
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Credential | DDS
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Telephone | 304-672-9994
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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