Provider Demographics
NPI:1770227415
Name:CARLBORG-DAVIS, MADELEINE B (DMD)
Entity Type:Individual
Prefix:
First Name:MADELEINE
Middle Name:B
Last Name:CARLBORG-DAVIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MADELEINE
Other - Middle Name:B
Other - Last Name:CARLBORG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 RIVERWALK TER STE 250
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-5619
Mailing Address - Country:US
Mailing Address - Phone:918-998-0996
Mailing Address - Fax:918-235-9079
Practice Address - Street 1:1629 POYNTZ AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-4148
Practice Address - Country:US
Practice Address - Phone:785-776-1771
Practice Address - Fax:785-539-3905
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS618391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice