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General NPI Number Information
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NPI Number | 1245676568
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Entity Type | Organization
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Legal Business Name | MAGNOLIA DENTAL LLC
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Dates
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Enumeration Date | 05/14/2013
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Last Update Date | 05/14/2013
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Provider Practice Location Address
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Address Line | 6061 PINNACLE PARKWAY
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City | COVINGTON
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State | LA
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Zip | 70433
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Country | US
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Telephone | 985-626-3348
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Fax |
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Provider Business Mailing Address
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Address Line | 1204 RUE DEGAS
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City | MANDEVILLE
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State | LA
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Zip | 70471-3056
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Country | US
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Telephone | 985-626-3348
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Fax |
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. ROSS WEBSTER QUARTANO
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Credential | D.D.S.
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Telephone | 985-626-3348
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 5979
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License Number State | LA
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