Provider Demographics
NPI:1124711270
Name:MALONE, MADISON DIETRICH (DDS)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:DIETRICH
Last Name:MALONE
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 1:1132 INN KEEPERS WAY
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-8166
Mailing Address - Country:US
Mailing Address - Phone:284-425-3598
Mailing Address - Fax:
Practice Address - Street 1:3711 ELMSLEY ST STE 106
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-7039
Practice Address - Country:US
Practice Address - Phone:336-754-8119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC132501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice