Provider Demographics
NPI:1184935959
Name:MADISON PEDIATRIC DENTISTRY LLC
Entity type:Organization
Organization Name:MADISON PEDIATRIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOFFETT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-792-0003
Mailing Address - Street 1:7559 HIGHWAY 72 W
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-8811
Mailing Address - Country:US
Mailing Address - Phone:256-527-4590
Mailing Address - Fax:256-890-4293
Practice Address - Street 1:7559 HIGHWAY 72 W
Practice Address - Street 2:SUITE C7/C8
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-8811
Practice Address - Country:US
Practice Address - Phone:256-527-4590
Practice Address - Fax:256-890-4293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-27
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty