Provider Demographics
NPI:1699484840
Name:CALLAWAY FAMILY DENTAL LLC
Entity type:Organization
Organization Name:CALLAWAY FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:MADOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-850-9285
Mailing Address - Street 1:2424 N BLUFF ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-2709
Mailing Address - Country:US
Mailing Address - Phone:573-642-6904
Mailing Address - Fax:
Practice Address - Street 1:2424 N BLUFF ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251-2709
Practice Address - Country:US
Practice Address - Phone:573-642-6904
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-16
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental