MEDICARE: MAGNOLIA DENTAL CENTER OF CLEVELAND, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1366284341
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA DENTAL CENTER OF CLEVELAND, LLC

Provider Business Mailing Address
First Line	:	1212 DODDS AVE
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37404-4754
Country	:	US
Telephone Number	:	423-206-9641
Fax Number	:

Provider Business Practice Location Address
First Line	:	2190 CHAMBLISS AVE NW
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37311-3839
Country	:	US
Telephone Number	:	423-476-3307
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SETH WEILER
Credential	:	DDS
Telephone Number	:	770-284-1395

Provider Enumeration Date	:	06/10/2024
Last Update Date	:	06/10/2024

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