MEDICARE: DENTAL ASSOCIATES OF MADISON, LLC

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	122300000X	Dentist	4231	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	51091741	OTHER	AL	BCBS AL
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952543779
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL ASSOCIATES OF MADISON, LLC

Provider Business Mailing Address
First Line	:	4072 SULLIVAN ST
Second Line	:	SUITE A
City	:	MADISON
State	:	AL
Zip	:	35758-3152
Country	:	US
Telephone Number	:	256-772-9988
Fax Number	:	256-772-9991

Provider Business Practice Location Address
First Line	:	4072 SULLIVAN ST
Second Line	:	SUITE A
City	:	MADISON
State	:	AL
Zip	:	35758-3152
Country	:	US
Telephone Number	:	256-772-9988
Fax Number	:	256-772-9991

Authorized Official
Title or Position	:	ADMINISTRATIVE ASSISTANT
Name	:	MRS. TERRI WRENN
Credential	:
Telephone Number	:	256-772-9988

Provider Enumeration Date	:	03/25/2009
Last Update Date	:	03/25/2009

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