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General NPI Number Information
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NPI Number | 1285560847
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Entity Type | Organization
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Legal Business Name | MAGNOLIA LANE DENTAL OF O FALLON LLC
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Dates
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Enumeration Date | 06/22/2026
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Last Update Date | 06/22/2026
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Provider Practice Location Address
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Address Line | 608 WOODLAWN AVE
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City | O FALLON
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State | MO
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Zip | 63366-2521
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Country | US
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Telephone | 217-779-4029
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Fax |
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Provider Business Mailing Address
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Address Line | 104 SUNNYSIDE ESTATES CT
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City | DARDENNE PRAIRIE
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State | MO
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Zip | 63368-7617
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Country | US
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Telephone | 217-779-4029
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | AUTUMN MALONEY
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Credential | DMD
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Telephone | 217-779-4029
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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