Healthcare Provider Details

I. General information

NPI: 1538230966
Provider Name (Legal Business Name): MADISON PEDIATRIC DENTAL, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 RIVER PL SUITE 110
MADISON WI
53716-4041
US

IV. Provider business mailing address

100 RIVER PL SUITE 110
MADISON WI
53716-4041
US

V. Phone/Fax

Practice location:
  • Phone: 608-222-6160
  • Fax: 608-222-6248
Mailing address:
  • Phone: 608-222-6160
  • Fax: 608-222-6248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JANET WILL
Title or Position: OFFICE MANAGER
Credential:
Phone: 608-222-6160