Provider Demographics
NPI:1528517430
Name:MADISON SQUARE FAMILY DENTAL
Entity type:Organization
Organization Name:MADISON SQUARE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BO
Authorized Official - Middle Name:
Authorized Official - Last Name:DING
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:404-992-1241
Mailing Address - Street 1:1925 MADISON SQUARE BLVD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:LA VERGNE
Mailing Address - State:TN
Mailing Address - Zip Code:37086-4721
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1925 MADISON SQUARE BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:LA VERGNE
Practice Address - State:TN
Practice Address - Zip Code:37086-4721
Practice Address - Country:US
Practice Address - Phone:404-992-1241
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10117261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental