Provider Demographics
NPI:1821031188
Name:MADAMBA, JORGE (DDS)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:MADAMBA
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 1:555 W BENJAMIN HOLT DR
Mailing Address - Street 2:BUILDING B
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-3839
Mailing Address - Country:US
Mailing Address - Phone:209-476-4700
Mailing Address - Fax:209-478-6890
Practice Address - Street 1:304 S AIR DEPOT BLVD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-4433
Practice Address - Country:US
Practice Address - Phone:405-733-0002
Practice Address - Fax:405-741-2230
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3173122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist