Healthcare Provider Details

I. General information

NPI: 1285560847
Provider Name (Legal Business Name): MAGNOLIA LANE DENTAL OF O FALLON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 WOODLAWN AVE
O FALLON MO
63366-2521
US

IV. Provider business mailing address

104 SUNNYSIDE ESTATES CT
DARDENNE PRAIRIE MO
63368-7617
US

V. Phone/Fax

Practice location:
  • Phone: 217-779-4029
  • Fax:
Mailing address:
  • Phone: 217-779-4029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: AUTUMN MALONEY
Title or Position: DENTIST
Credential: DMD
Phone: 217-779-4029