Provider Demographics
NPI:1588414809
Name:PARRIS-BACON, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:PARRIS-BACON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2277 ALBION ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80207-3707
Mailing Address - Country:US
Mailing Address - Phone:303-349-7244
Mailing Address - Fax:
Practice Address - Street 1:811 W WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5123
Practice Address - Country:US
Practice Address - Phone:773-871-2188
Practice Address - Fax:773-871-6353
Is Sole Proprietor?:No
Enumeration Date:2024-03-27
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL019.0352281223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDental Anesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program