Provider Demographics
NPI:1568106524
Name:THOMAS, MADISON NICOLE (RDH)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:NICOLE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:NICOLE
Other - Last Name:SMALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:3455 S KINGS AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5119
Mailing Address - Country:US
Mailing Address - Phone:417-496-5879
Mailing Address - Fax:
Practice Address - Street 1:104 PLANTERS CT
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-8581
Practice Address - Country:US
Practice Address - Phone:417-496-5879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALH-0009209-C1124Q00000X
MO2020016233124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist