Provider Demographics
NPI:1912088915
Name:MADDEN, MARK JAMES
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JAMES
Last Name:MADDEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 ELM AE
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-9183
Mailing Address - Country:US
Mailing Address - Phone:763-972-2800
Mailing Address - Fax:763-972-9064
Practice Address - Street 1:707 ELM AVE
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:MN
Practice Address - Zip Code:55313-9183
Practice Address - Country:US
Practice Address - Phone:763-972-2800
Practice Address - Fax:763-972-9036
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice