Healthcare Provider Details

I. General information

NPI: 1629911698
Provider Name (Legal Business Name): MAGNOLIA ORTHODONTICS OF PETAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 BEECH LN
PETAL MS
39465-9457
US

IV. Provider business mailing address

35 BEECH LN
PETAL MS
39465-9457
US

V. Phone/Fax

Practice location:
  • Phone: 601-305-9955
  • Fax: 601-305-9977
Mailing address:
  • Phone: 601-305-9955
  • Fax: 601-305-9977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. SARAH KIMBROUGH
Title or Position: OWNER
Credential: DMD, MDS
Phone: 601-466-8562