Country Club Dental PLLC

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

Legal business name

COUNTRY CLUB DENTAL PLLC

Practice address

1520 Country Club Rd
Fairmont, WV 26554-1353

Phone

(304) 363-9160

NPI assigned

Nov 18, 2025

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Nadia Mardmomen, DDSNPI 1720662471

Title

Member

Phone

(304) 672-9994

Specialties & licenses 1

Addresses

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Nadia Mardmomen, DDS

  • General Practice Dentistry
  • Bridgeport, WV
  • NPI 1720662471
  NPD Authorized official
• Douglas Clark Hannah, DDS

  • Dentist
  • Fairmont, WV
  • NPI 1184707580
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1763424000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1763424000000",
    "number": "1821959131",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "80 GARDEN CIR",
            "city": "BRIDGEPORT",
            "state": "WV",
            "postal_code": "263301367",
            "telephone_number": "304-672-9994"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1520 COUNTRY CLUB RD",
            "city": "FAIRMONT",
            "state": "WV",
            "postal_code": "265541353",
            "telephone_number": "304-363-9160"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COUNTRY CLUB DENTAL PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2025-11-18",
        "last_updated": "2025-11-18",
        "certification_date": "2025-11-18",
        "status": "A",
        "authorized_official_last_name": "MARDMOMEN",
        "authorized_official_first_name": "NADIA",
        "authorized_official_title_or_position": "MEMBER",
        "authorized_official_telephone_number": "304-672-9994",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Clinton Tyler Cosner, DPT
• Azlynn Danae Cottingham
• Kimberlee Cottingham
• Misty Monique Cottingham
• Rachel Cottrill
• Country Roads Physical Therapy and Rehabilitation
• Charles Wilson Counts
• Kathern Ashleymarie Counts
• County of Marion Board of Health
• Patrica Ann Courtney, RN

• General Practice Dentistry in Fairmont, WV
• Providers in Fairmont, WV by specialty
• General Practice Dentistry in West Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 18, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.