Provider Demographics
NPI:1477687580
Name:MADISON, MILES (DDS)
Entity Type:Individual
Prefix:DR
First Name:MILES
Middle Name:
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 1:3131 SANTA ANITA AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91733-1369
Mailing Address - Country:US
Mailing Address - Phone:626-444-2605
Mailing Address - Fax:626-444-0615
Practice Address - Street 1:3131 SANTA ANITA AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91733-1369
Practice Address - Country:US
Practice Address - Phone:626-444-2605
Practice Address - Fax:626-444-0615
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374461223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB37446Medicaid