Provider Demographics
NPI:1679732432
Name:MADDOX, MARK GLENN (DDS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:GLENN
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:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:TUOLUMNE
Mailing Address - State:CA
Mailing Address - Zip Code:95379
Mailing Address - Country:US
Mailing Address - Phone:209-928-4262
Mailing Address - Fax:
Practice Address - Street 1:18400 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:TUOLUMNE
Practice Address - State:CA
Practice Address - Zip Code:95379
Practice Address - Country:US
Practice Address - Phone:209-928-4262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23849D122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist