Provider Demographics
NPI:1497175897
Name:MADDOX, JACQUELINE
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:MADDOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 43RD ST
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-2326
Mailing Address - Country:US
Mailing Address - Phone:631-245-4107
Mailing Address - Fax:
Practice Address - Street 1:1125 SMITHTOWN AVE
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-2160
Practice Address - Country:US
Practice Address - Phone:631-589-8585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-24
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057987122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist