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General NPI Number Information
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NPI Number | 1194542928
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Entity Type | Organization
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Legal Business Name | MAGNOLIA LANE GA PARTNERS LLC
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Dates
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Enumeration Date | 09/23/2024
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Last Update Date | 11/24/2025
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Provider Practice Location Address
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Address Line | 1235 ROBINSON RD STE H
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City | PEACHTREE CITY
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State | GA
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Zip | 30269-3832
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Country | US
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Telephone | 770-487-1880
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Fax | 770-487-1851
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Provider Business Mailing Address
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Address Line | 1235 ROBINSON RD STE H
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City | PEACHTREE CITY
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State | GA
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Zip | 30269-3832
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Country | US
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Telephone | 770-487-1880
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Fax | 770-487-1851
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Authorized Official
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Title or Position | OWNER
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Name | DR. JACQUELINE DELASH
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Credential | DMD, MPH, MBA, D. AB
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Telephone | 770-336-7074
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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