Healthcare Provider Details

I. General information

NPI: 1841664927
Provider Name (Legal Business Name): MADAN PERIODONTICS AND IMPLANT DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2015
Last Update Date: 11/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 E VIRGINIA BEACH BLVD STE 213
NORFOLK VA
23502-2487
US

IV. Provider business mailing address

5900 E VIRGINIA BEACH BLVD STE 213
NORFOLK VA
23502-2487
US

V. Phone/Fax

Practice location:
  • Phone: 757-461-3660
  • Fax:
Mailing address:
  • Phone: 757-461-3660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number0401412643
License Number StateVA

VIII. Authorized Official

Name: DR. MONIKA MADAN
Title or Position: PERIODONTIST/CEO
Credential: DDS DSC
Phone: 757-663-1633