Healthcare Provider Details

I. General information

NPI: 1205475332
Provider Name (Legal Business Name): MARK ALEXANDER MADION DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2020
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5698W US HIGHWAY 2
MANISTIQUE MI
49854-9116
US

IV. Provider business mailing address

508 BLOOMFIELD RD
TRAVERSE CITY MI
49686-2833
US

V. Phone/Fax

Practice location:
  • Phone: 906-341-8469
  • Fax:
Mailing address:
  • Phone: 231-632-0606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901600397
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: