Provider Demographics
NPI:1790343051
Name:MADISON DENTAL SPA
Entity Type:Organization
Organization Name:MADISON DENTAL SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MOUMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALMOUZAYN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-245-5121
Mailing Address - Street 1:90 WALL ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-3128
Mailing Address - Country:US
Mailing Address - Phone:203-245-5101
Mailing Address - Fax:203-245-5121
Practice Address - Street 1:90 WALL ST STE 100
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-3128
Practice Address - Country:US
Practice Address - Phone:203-245-5101
Practice Address - Fax:203-245-5121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental