Provider Demographics
NPI:1245789122
Name:MADDEN FAMILY DENTISTRY
Entity Type:Organization
Organization Name:MADDEN FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-963-3412
Mailing Address - Street 1:3358 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:NY
Mailing Address - Zip Code:13114-3002
Mailing Address - Country:US
Mailing Address - Phone:315-963-3412
Mailing Address - Fax:
Practice Address - Street 1:3358 MAIN ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:NY
Practice Address - Zip Code:13114-3002
Practice Address - Country:US
Practice Address - Phone:315-963-3412
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034937261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental