Provider Demographics
NPI:1639854276
Name:MADDY, SU MIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SU
Middle Name:MIN
Last Name:MADDY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 LEXINGTON RD
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4466
Mailing Address - Country:US
Mailing Address - Phone:575-762-2355
Mailing Address - Fax:
Practice Address - Street 1:821 LEXINGTON RD
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4466
Practice Address - Country:US
Practice Address - Phone:575-762-2355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-20
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDB-2023-01271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice