1093849226 NPI number — MADISON PARK DENTAL CENTER PLLC

Table of content: (NPI 1093849226)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093849226 NPI number — MADISON PARK DENTAL CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MADISON PARK DENTAL CENTER PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093849226
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35 MADISON PROFESSIONAL PARK
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REXBURG
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-356-5601
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 MADISON PROFESSIONAL PARK
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REXBURG
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-356-5601
Provider Business Practice Location Address Fax Number:
208-356-8788
Provider Enumeration Date:
03/16/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WALKER
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
208-356-5601

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D1657 D3634 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6I120 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 80659700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6I138 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".