Healthcare Provider Details

I. General information

NPI: 1598454498
Provider Name (Legal Business Name): MADISON NII
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11151 ROBINWOOD DR
HAGERSTOWN MD
21742-6703
US

IV. Provider business mailing address

9471 N WOODMONT DR
FRESNO CA
93720-0875
US

V. Phone/Fax

Practice location:
  • Phone: 559-977-7759
  • Fax:
Mailing address:
  • Phone: 559-977-7759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number18826
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: