Provider Demographics
NPI:1851551147
Name:MADISON DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:MADISON DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:ZGODINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:440-428-1101
Mailing Address - Street 1:6248 N RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:44057-2567
Mailing Address - Country:US
Mailing Address - Phone:440-428-1101
Mailing Address - Fax:440-428-6985
Practice Address - Street 1:6248 N RIDGE RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:OH
Practice Address - Zip Code:44057-2567
Practice Address - Country:US
Practice Address - Phone:440-428-1101
Practice Address - Fax:440-428-6985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300180021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0753788Medicaid