Provider Demographics
NPI:1639794266
Name:MADDOX, MATTHEW ISAAC (DDS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ISAAC
Last Name:MADDOX
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 1:1040 FLYNN RD
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-5092
Mailing Address - Country:US
Mailing Address - Phone:805-673-3930
Mailing Address - Fax:805-659-3217
Practice Address - Street 1:1000 NEWBURY RD STE 150
Practice Address - Street 2:
Practice Address - City:NEWBURY PARK
Practice Address - State:CA
Practice Address - Zip Code:91320-6438
Practice Address - Country:US
Practice Address - Phone:805-498-3640
Practice Address - Fax:805-498-3641
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2023-07-27
Deactivation Date:2021-10-06
Deactivation Code:
Reactivation Date:2021-10-26
Provider Licenses
StateLicense IDTaxonomies
CA107036122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist