MEDICARE: MADISON DENTAL, DDS, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	25589	TX

General Provider Information

NPI Number	:	1871838029
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MADISON DENTAL, DDS, PC

Provider Business Mailing Address
First Line	:	566 FM 1960 RD W STE 400
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77090-3544
Country	:	US
Telephone Number	:	202-491-5781
Fax Number	:

Provider Business Practice Location Address
First Line	:	566 FM 1960 RD W STE 400
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77090-3544
Country	:	US
Telephone Number	:	202-491-5781
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CARLOS RODQUAE BOSTON
Credential	:	DDS
Telephone Number	:	202-491-5781

Provider Enumeration Date	:	11/28/2012
Last Update Date	:	11/28/2012

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