Provider Demographics
NPI:1750989992
Name:OLDHAM, MAXWELL (DDS)
Entity type:Individual
Prefix:
First Name:MAXWELL
Middle Name:
Last Name:OLDHAM
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 1:1823 BASIN TRL
Mailing Address - Street 2:
Mailing Address - City:BRENHAM
Mailing Address - State:TX
Mailing Address - Zip Code:77833-3963
Mailing Address - Country:US
Mailing Address - Phone:512-740-2290
Mailing Address - Fax:
Practice Address - Street 1:115 KOHLERS XING STE 350
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-2467
Practice Address - Country:US
Practice Address - Phone:512-256-7886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-10
Last Update Date:2020-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX345381223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty