Provider Demographics
NPI:1497260152
Name:MADISON STREET DENTAL LLC
Entity Type:Organization
Organization Name:MADISON STREET DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-339-3172
Mailing Address - Street 1:1699 E WOODFIELD RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4955
Mailing Address - Country:US
Mailing Address - Phone:630-339-3172
Mailing Address - Fax:
Practice Address - Street 1:210 N MADISON ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-3450
Practice Address - Country:US
Practice Address - Phone:815-338-7569
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019015666261QD0000X
IL019018403261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental