Provider Demographics
NPI:1083225189
Name:MADISON DENTAL STUDIO
Entity Type:Organization
Organization Name:MADISON DENTAL STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:LONG
Authorized Official - Last Name:PAPPA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:256-335-7042
Mailing Address - Street 1:157 REUNION DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7142
Mailing Address - Country:US
Mailing Address - Phone:256-335-7042
Mailing Address - Fax:
Practice Address - Street 1:119 COLONY CROSSING WAY STE 780
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6327
Practice Address - Country:US
Practice Address - Phone:769-300-1001
Practice Address - Fax:769-300-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-12
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty