=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043533623
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGNOLIA FAMILY DENTISTRY OF COLUMBUS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2010
-----------------------------------------------------
Last Update Date | 03/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2401 5TH ST N STE 2
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39705-2005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-328-8001
-----------------------------------------------------
Fax | 888-852-8644
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2401 5TH ST N STE 2
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39705-2005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-328-8001
-----------------------------------------------------
Fax | 888-852-8644
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | DR. DONNIE J. RICHARDSON JR.
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 662-328-8001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 1860-79
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 3160-00
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 3463-08
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------