Provider Demographics
NPI:1750081881
Name:VALLEJO, MADELINE WILLER
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:WILLER
Last Name:VALLEJO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:ELIZABETH
Other - Last Name:WILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:54 N LOCHWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77375-0217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3600 FM 1488 RD STE 90
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77384-3818
Practice Address - Country:US
Practice Address - Phone:936-271-5440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2025-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX406231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice