Provider Demographics
NPI:1144261199
Name:MADISON ORAL & MAXILLOFACIAL SURGEONS SC
Entity type:Organization
Organization Name:MADISON ORAL & MAXILLOFACIAL SURGEONS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:G
Authorized Official - Last Name:STRONCEK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-274-0770
Mailing Address - Street 1:5801 RESEARCH PARK BLVD
Mailing Address - Street 2:STE 110
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-6002
Mailing Address - Country:US
Mailing Address - Phone:608-274-7711
Mailing Address - Fax:608-274-9224
Practice Address - Street 1:5801 RESEARCH PARK BLVD
Practice Address - Street 2:STE 110
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-6002
Practice Address - Country:US
Practice Address - Phone:608-274-7711
Practice Address - Fax:608-274-9224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38358100Medicaid
WI407050OtherDEAN HEALTH PLAN GROUP