Provider Demographics
NPI:1437417649
Name:MADISON DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:MADISON DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-973-6621
Mailing Address - Street 1:189 SW CAPTAIN BROWN RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:FL
Mailing Address - Zip Code:32340-4351
Mailing Address - Country:US
Mailing Address - Phone:850-973-6621
Mailing Address - Fax:850-973-6672
Practice Address - Street 1:189 SW CAPTAIN BROWN RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340-4351
Practice Address - Country:US
Practice Address - Phone:850-973-6621
Practice Address - Fax:850-973-6672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty