Provider Demographics
NPI:1881850105
Name:MADSON, STACEY ERICA (DDS)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:ERICA
Last Name:MADSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:STACEY
Other - Middle Name:ERICA MADSON
Other - Last Name:REUSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1111 W VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-1485
Mailing Address - Country:US
Mailing Address - Phone:920-733-1111
Mailing Address - Fax:920-380-4056
Practice Address - Street 1:1111 W VALLEY RD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1485
Practice Address - Country:US
Practice Address - Phone:920-733-1111
Practice Address - Fax:920-380-4056
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6286-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice