# MADISON PARK DENTAL CENTER PLLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1093849226
- **Authorized official:** DR. ROBERT L WALKER (PRESIDENT)
- **Authorized official phone:** (208) 356-5601

## Contact information

- **Practice address:** 35 MADISON PROFESSIONAL PARK, REXBURG, ID 83440
- **Practice address phone:** (208) 356-5601
- **Practice address fax:** (208) 356-8788
- **Mailing address:** 35 MADISON PROFESSIONAL PARK, REXBURG, ID 83440
- **Mailing address phone:** (208) 356-5601

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | D1657 D3634 | ID | Yes |

## Other

- **Enumeration date:** 03/16/2007
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 6I120 | BLUE CROSS | ID |
| 01 | — | 6I138 | BLUE CROSS | ID |
| 05 | — | 80659700 | — | ID |