Healthcare Provider Details

I. General information

NPI: 1720151582
Provider Name (Legal Business Name): MADISON COUNTY DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 NORTH MAIN STREET
MADISON VA
22727
US

IV. Provider business mailing address

PO BOX 67 410 NORTH MAIN STREET
MADISON VA
22727
US

V. Phone/Fax

Practice location:
  • Phone: 540-948-5481
  • Fax: 540-948-3841
Mailing address:
  • Phone: 540-948-5481
  • Fax: 540-948-3841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: THOMAS JOHNSON
Title or Position: PUBLIC HEALTH DENTIST
Credential: DDS
Phone: 540-347-6400