=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326518119
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGNOLIA FAMILY DENTISTRY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2018
-----------------------------------------------------
Last Update Date | 12/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1791 NW 173RD AVE STE 110
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97006-5630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-372-5527
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1791 NW 173RD AVE STE 110
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97006-5630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-372-5527
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. MIRA DELLA CROCE
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 503-372-5527
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------