Provider Demographics
NPI:1407070535
Name:DANIEL S MAUDLIN DDS PC
Entity Type:Organization
Organization Name:DANIEL S MAUDLIN DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:SYDNEY
Authorized Official - Last Name:MAUDLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:269-327-4473
Mailing Address - Street 1:3060 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4825
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3060 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4825
Practice Address - Country:US
Practice Address - Phone:269-327-4473
Practice Address - Fax:269-327-1174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI107021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty