Provider Demographics
NPI:1871838029
Name:MADISON DENTAL, DDS, PC
Entity Type:Organization
Organization Name:MADISON DENTAL, DDS, PC
Other - Org Name:MADISON DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:RODQUAE
Authorized Official - Last Name:BOSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:202-491-5781
Mailing Address - Street 1:566 FM 1960 RD W STE 400
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-3544
Mailing Address - Country:US
Mailing Address - Phone:202-491-5781
Mailing Address - Fax:
Practice Address - Street 1:566 FM 1960 RD W STE 400
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-3544
Practice Address - Country:US
Practice Address - Phone:202-491-5781
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX255891223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty