Provider Demographics
NPI:1205139821
Name:MADDOX, RAYMOND MATTHEW (DDS)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:MATTHEW
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 1:1270 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590
Mailing Address - Country:US
Mailing Address - Phone:317-432-4753
Mailing Address - Fax:
Practice Address - Street 1:1270 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-1930
Practice Address - Country:US
Practice Address - Phone:608-825-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-21
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011570A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice