Provider Demographics
NPI:1508441981
Name:MADRIGAL, MASSIEL DEL CARMEN
Entity Type:Individual
Prefix:
First Name:MASSIEL
Middle Name:DEL CARMEN
Last Name:MADRIGAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9738 SW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-4352
Mailing Address - Country:US
Mailing Address - Phone:561-376-3537
Mailing Address - Fax:
Practice Address - Street 1:3980 S MILITARY TRL
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33463-3434
Practice Address - Country:US
Practice Address - Phone:561-467-4439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDRPM2272390200000X
FLDN280431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program