Provider Demographics
NPI:1083074736
Name:MADDOX, MELANIE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:MADDOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6805 W DAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93656
Mailing Address - Country:US
Mailing Address - Phone:1559-960-4920
Mailing Address - Fax:
Practice Address - Street 1:305 E CENTER AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-6331
Practice Address - Country:US
Practice Address - Phone:877-960-3426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA101951122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program