Provider Demographics
NPI:1720670052
Name:BILDERBACK, MAXWELL JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MAXWELL
Middle Name:JOHN
Last Name:BILDERBACK
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 1:1050 TIMBERWALE LN NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-2837
Mailing Address - Country:US
Mailing Address - Phone:678-451-2040
Mailing Address - Fax:
Practice Address - Street 1:100 COURTYARD DR SE
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-8523
Practice Address - Country:US
Practice Address - Phone:770-382-5678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1222261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice