Basic Information
| Provider Information | |||||||||
| NPI: | 1134675747 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADSEN | ||||||||
| FirstName: | JAKE | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 652 HAMILTON RD. | ||||||||
| Address2: | |||||||||
| City: | FORT SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804424002 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 652 HAMILTON RD. | ||||||||
| Address2: | |||||||||
| City: | FORT SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804423905 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2016 | ||||||||
| LastUpdateDate: | 09/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 9809328-9922 | UT | Y | Dental Providers | Dentist | General Practice |
No ID Information.