Healthcare Provider Details

I. General information

NPI: 1285556563
Provider Name (Legal Business Name): ETHAN MADISON, DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 S BEVERLY DR STE 160
BEVERLY HILLS CA
90212-4815
US

IV. Provider business mailing address

350 S BEVERLY DR STE 160
BEVERLY HILLS CA
90212-4815
US

V. Phone/Fax

Practice location:
  • Phone: 310-713-9548
  • Fax:
Mailing address:
  • Phone: 310-713-9548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. ETHAN SEAN MADISON
Title or Position: PRESIDENT
Credential: DDS
Phone: 310-713-9548