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General NPI Number Information
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NPI Number | 1558536706
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Entity Type | Organization
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Legal Business Name | MAGNOLIA DENTAL
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Dates
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Enumeration Date | 04/29/2008
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Last Update Date | 04/29/2008
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Provider Practice Location Address
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Address Line | 9625 WESTVIEW DR
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City | CORAL SPRINGS
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State | FL
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Zip | 33076-2513
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Country | US
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Telephone | 954-227-1417
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Fax | 954-227-0197
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Provider Business Mailing Address
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Address Line | 9625 WESTVIEW DR
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City | CORAL SPRINGS
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State | FL
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Zip | 33076-2513
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Country | US
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Telephone | 954-227-1417
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Fax | 954-227-0197
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Authorized Official
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Title or Position | DR
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Name | DR. RALPH C COLLAZO
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Credential | DDS
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Telephone | 954-227-1417
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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 | DN0012295
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License Number State | FL
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