Provider Demographics
NPI:1417290479
Name:MADSEN, JUSTIN SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:SCOTT
Last Name:MADSEN
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 1:2301 N 36TH ST STE 102
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-336-8801
Mailing Address - Fax:208-336-8682
Practice Address - Street 1:2301 N 26TH ST STE 102
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-336-8801
Practice Address - Fax:208-336-8682
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-28
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-45721223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program