Provider Demographics
NPI:1114658929
Name:MADDALENA, ALEC EDWARD (DDS)
Entity Type:Individual
Prefix:
First Name:ALEC
Middle Name:EDWARD
Last Name:MADDALENA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42301 CHERRY HILL RD STE D
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-1200
Mailing Address - Country:US
Mailing Address - Phone:734-981-4040
Mailing Address - Fax:
Practice Address - Street 1:42301 CHERRY HILL RD STE D
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-1200
Practice Address - Country:US
Practice Address - Phone:734-981-4040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-22
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601333122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty