Provider Demographics
NPI:1093167884
Name:R MATTHEW MADDOX DENTISTRY, LLC
Entity Type:Organization
Organization Name:R MATTHEW MADDOX DENTISTRY, LLC
Other - Org Name:MADDOX FAMILY DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:MADDOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-348-4111
Mailing Address - Street 1:1200 N WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD CITY
Mailing Address - State:IN
Mailing Address - Zip Code:47348-1338
Mailing Address - Country:US
Mailing Address - Phone:765-348-4111
Mailing Address - Fax:
Practice Address - Street 1:1200 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:HARTFORD CITY
Practice Address - State:IN
Practice Address - Zip Code:47348-1338
Practice Address - Country:US
Practice Address - Phone:765-348-4111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011570A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty