Provider Demographics
NPI:1457029167
Name:MADRIGAL WALLE, PABLO (DDS)
Entity Type:Individual
Prefix:
First Name:PABLO
Middle Name:
Last Name:MADRIGAL WALLE
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 1:1547 CONCERTO LN # LM
Mailing Address - Street 2:
Mailing Address - City:HUGHSON
Mailing Address - State:CA
Mailing Address - Zip Code:95326-9136
Mailing Address - Country:US
Mailing Address - Phone:209-484-3078
Mailing Address - Fax:
Practice Address - Street 1:3100 E SERVICE RD
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-6422
Practice Address - Country:US
Practice Address - Phone:209-542-9921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106838122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist