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General NPI Number Information
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NPI Number | 1689183642
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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 | 09/21/2017
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Last Update Date | 09/21/2017
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Provider Practice Location Address
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Address Line | 3801 S HURSTBOURNE PKWY
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City | LOUISVILLE
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State | KY
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Zip | 40299-7319
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Country | US
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Telephone | 502-709-9430
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Fax |
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Provider Business Mailing Address
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Address Line | 3801 S HURSTBOURNE PKWY
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City | LOUISVILLE
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State | KY
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Zip | 40299-7319
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CHARLES E CROWL
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Credential | DDS
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Telephone | 502-709-9430
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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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