Provider Demographics
NPI:1154423127
Name:MADRIGAL, DORIS (DDS)
Entity type:Individual
Prefix:
First Name:DORIS
Middle Name:
Last Name:MADRIGAL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 N CROOKED LAKE LANE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-6438
Mailing Address - Country:US
Mailing Address - Phone:847-265-8539
Mailing Address - Fax:
Practice Address - Street 1:1228 N CEDAR LAKE RD
Practice Address - Street 2:SUITE C
Practice Address - City:ROUND LAKE BEACH
Practice Address - State:IL
Practice Address - Zip Code:60073-2556
Practice Address - Country:US
Practice Address - Phone:847-740-8827
Practice Address - Fax:847-740-7388
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-02276201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1002800-102967Medicaid