Provider Demographics
NPI:1912090986
Name:MADDOX, TIMOTHY BLAKE (DMD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:BLAKE
Last Name:MADDOX
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 1:211 N MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WARRIOR
Mailing Address - State:AL
Mailing Address - Zip Code:35180
Mailing Address - Country:US
Mailing Address - Phone:205-647-3181
Mailing Address - Fax:205-647-1134
Practice Address - Street 1:211 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:WARRIOR
Practice Address - State:AL
Practice Address - Zip Code:35180
Practice Address - Country:US
Practice Address - Phone:205-647-3181
Practice Address - Fax:205-647-1134
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL49441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice