Provider Demographics
NPI:1336134956
Name:MADISON, GARY ADDISON (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ADDISON
Last Name:MADISON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 LISA WAY
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92027-1172
Mailing Address - Country:US
Mailing Address - Phone:760-745-6202
Mailing Address - Fax:
Practice Address - Street 1:1411 LISA WAY
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92027-1172
Practice Address - Country:US
Practice Address - Phone:760-745-6202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26471122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist