# COUNTRY CLUB DENTAL PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1821959131
- **Authorized official:** DR. NADIA MARDMOMEN DDS (MEMBER)
- **Authorized official phone:** (304) 672-9994

## Contact information

- **Practice address:** 1520 COUNTRY CLUB RD, FAIRMONT, WV 26554-1353
- **Practice address phone:** (304) 363-9160
- **Mailing address:** 80 GARDEN CIR, BRIDGEPORT, WV 26330-1367
- **Mailing address phone:** (304) 672-9994

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | — | — | Yes |

## Other

- **Enumeration date:** 11/18/2025
- **Last updated:** 11/18/2025