Provider Demographics
NPI:1356025530
Name:ETLING, MADISON CLARE (DDS)
Entity type:Individual
Prefix:DR
First Name:MADISON
Middle Name:CLARE
Last Name:ETLING
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:738 VISTA GLEN CT
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-2086
Mailing Address - Country:US
Mailing Address - Phone:314-619-9512
Mailing Address - Fax:
Practice Address - Street 1:4620 HAMPTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-2714
Practice Address - Country:US
Practice Address - Phone:314-752-7468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023021431122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice