Provider Demographics
NPI:1497843361
Name:MADISON, GARY JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:JOHN
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 1:324 W SUPERIOR ST
Mailing Address - Street 2:SUITE 700
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1701
Mailing Address - Country:US
Mailing Address - Phone:218-722-7831
Mailing Address - Fax:218-625-5550
Practice Address - Street 1:324 W SUPERIOR ST
Practice Address - Street 2:SUITE 700
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1701
Practice Address - Country:US
Practice Address - Phone:218-722-7831
Practice Address - Fax:218-625-5550
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND105211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice