Provider Demographics
NPI:1750435152
Name:MADDOX BROTHERS, DEANNA MARIE (DDS)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:MARIE
Last Name:MADDOX BROTHERS
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:PO BOX 8979
Mailing Address - Street 2:937 SAN FRANCISCO AVE
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96158
Mailing Address - Country:US
Mailing Address - Phone:530-544-2441
Mailing Address - Fax:530-544-2179
Practice Address - Street 1:937 SAN FRANCISCO AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150
Practice Address - Country:US
Practice Address - Phone:530-544-2441
Practice Address - Fax:530-544-2179
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA036732122300000X
NV4773T122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist