Provider Demographics
NPI:1164977997
Name:MACK, MADISON (DDS)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3008 H G MOSLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-2948
Mailing Address - Country:US
Mailing Address - Phone:903-236-4050
Mailing Address - Fax:903-753-4426
Practice Address - Street 1:3008 H G MOSLEY PKWY
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-2948
Practice Address - Country:US
Practice Address - Phone:903-236-4050
Practice Address - Fax:903-753-4426
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32168122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist