Provider Demographics
NPI:1902034382
Name:ATTRIDGE, JOAN MAZA (DDS)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:MAZA
Last Name:ATTRIDGE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 7TH ST NW
Mailing Address - Street 2:
Mailing Address - City:CASS LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56633-3360
Mailing Address - Country:US
Mailing Address - Phone:218-355-3230
Mailing Address - Fax:218-335-3368
Practice Address - Street 1:1201 HERITAGE CIR
Practice Address - Street 2:
Practice Address - City:PAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74058-3744
Practice Address - Country:US
Practice Address - Phone:918-762-6561
Practice Address - Fax:187-623-5439
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020044122300000X
MNS1411223P0221X
OK1401223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901020044OtherMICHIGAN DENTAL LICENSE