Provider Demographics
NPI:1841664927
Name:MADAN PERIODONTICS AND IMPLANT DENTISTRY PLLC
Entity type:Organization
Organization Name:MADAN PERIODONTICS AND IMPLANT DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MONIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS DSC
Authorized Official - Phone:757-663-1633
Mailing Address - Street 1:5900 E VIRGINIA BEACH BLVD STE 213
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-2487
Mailing Address - Country:US
Mailing Address - Phone:757-461-3660
Mailing Address - Fax:
Practice Address - Street 1:5900 E VIRGINIA BEACH BLVD STE 213
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-2487
Practice Address - Country:US
Practice Address - Phone:757-461-3660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-30
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014126431223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty