Provider Demographics
NPI:1720662471
Name:MARDMOMEN, NADIA (DDS)
Entity Type:Individual
Prefix:
First Name:NADIA
Middle Name:
Last Name:MARDMOMEN
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 1:11 WOODBROOK LN
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1047
Mailing Address - Country:US
Mailing Address - Phone:304-672-9994
Mailing Address - Fax:
Practice Address - Street 1:9 CHENOWETH DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1885
Practice Address - Country:US
Practice Address - Phone:304-842-1921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV45331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice