Provider Demographics
NPI:1720246531
Name:MADISON FAMILY DENTISTRY
Entity Type:Organization
Organization Name:MADISON FAMILY DENTISTRY
Other - Org Name:JESSE W. DUQUETTE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:DUQUETTE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-273-6744
Mailing Address - Street 1:1739 MICHIGAN RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-2721
Mailing Address - Country:US
Mailing Address - Phone:812-273-6744
Mailing Address - Fax:812-265-4025
Practice Address - Street 1:1739 MICHIGAN RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-2721
Practice Address - Country:US
Practice Address - Phone:812-273-6744
Practice Address - Fax:812-265-4025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010146A122300000X
KY38531223P0221X
IN81741223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200527470-AMedicaid
IN678416OtherUNITED CONCORDIA