Provider Demographics
NPI:1033243498
Name:MADISON A DENTAL CORPORATION
Entity Type:Organization
Organization Name:MADISON A DENTAL CORPORATION
Other - Org Name:ATLAS DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MILES
Authorized Official - Middle Name:
Authorized Official - Last Name:MADISON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-444-2605
Mailing Address - Street 1:2732 SANTA ANITA AVE
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91733-2262
Mailing Address - Country:US
Mailing Address - Phone:626-444-2605
Mailing Address - Fax:626-444-0615
Practice Address - Street 1:2732 SANTA ANITA AVE
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91733-2262
Practice Address - Country:US
Practice Address - Phone:626-444-2605
Practice Address - Fax:626-444-0615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93341-01Medicare ID - Type UnspecifiedBILLING PROVIDER NUMBER