Provider Demographics
NPI:1922165943
Name:THOMAS J MADL JR DMD, LLC
Entity Type:Organization
Organization Name:THOMAS J MADL JR DMD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MADL
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:513-367-4048
Mailing Address - Street 1:1003 HARRISON AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:HARRISON
Mailing Address - State:OH
Mailing Address - Zip Code:45030-1799
Mailing Address - Country:US
Mailing Address - Phone:513-367-4048
Mailing Address - Fax:513-367-4068
Practice Address - Street 1:1003 HARRISON AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:HARRISON
Practice Address - State:OH
Practice Address - Zip Code:45030-1799
Practice Address - Country:US
Practice Address - Phone:513-367-4048
Practice Address - Fax:513-367-4068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300206641223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2038244Medicaid