Provider Demographics
NPI:1619718293
Name:MINDIOLA, MAXWELL MIGUEL (DDS)
Entity type:Individual
Prefix:DR
First Name:MAXWELL
Middle Name:MIGUEL
Last Name:MINDIOLA
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 1:5909 SHARPSBURG DR APT 504
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53718-3052
Mailing Address - Country:US
Mailing Address - Phone:262-470-6948
Mailing Address - Fax:
Practice Address - Street 1:2630 LIBERTY LN
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-0717
Practice Address - Country:US
Practice Address - Phone:608-752-2931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001541-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist