Provider Demographics
NPI:1962977025
Name:MADAN, ANIL KUMAR (DMD)
Entity type:Individual
Prefix:
First Name:ANIL KUMAR
Middle Name:
Last Name:MADAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7225 9TH AVE APT 1225
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77642-2093
Mailing Address - Country:US
Mailing Address - Phone:617-453-4537
Mailing Address - Fax:
Practice Address - Street 1:3109 EDGAR BROWN DR STE H
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77630-5381
Practice Address - Country:US
Practice Address - Phone:409-330-4252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX346781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice