Provider Demographics
NPI:1740398379
Name:MADDOX III, BROOKS WELLS (DMD)
Entity Type:Individual
Prefix:DR
First Name:BROOKS
Middle Name:WELLS
Last Name:MADDOX III
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2292 MOUNT ZION RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-2528
Mailing Address - Country:US
Mailing Address - Phone:770-477-6020
Mailing Address - Fax:
Practice Address - Street 1:2292 MOUNT ZION RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-2528
Practice Address - Country:US
Practice Address - Phone:770-477-6020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0111601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice