Provider Demographics
NPI:1164624433
Name:MADSEN, MATTHEW JAMES (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JAMES
Last Name:MADSEN
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:839 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3401
Mailing Address - Country:US
Mailing Address - Phone:859-806-3925
Mailing Address - Fax:
Practice Address - Street 1:839 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3401
Practice Address - Country:US
Practice Address - Phone:859-806-3925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY84801223S0112X
CA625461223S0112X
CAA1252741223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty