Provider Demographics
NPI:1699664011
Name:MADSEN, KALEB
Entity type:Individual
Prefix:
First Name:KALEB
Middle Name:
Last Name:MADSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 NEVADA CIR
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5433
Mailing Address - Country:US
Mailing Address - Phone:801-822-3222
Mailing Address - Fax:
Practice Address - Street 1:1601 S SECOND ST
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5816
Practice Address - Country:US
Practice Address - Phone:505-722-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-01
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDB-2025-01111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice