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General NPI Number Information
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NPI Number | 1689911471
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Entity Type | Organization
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Legal Business Name | MAGNOLIA FAMILY DENTAL
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Dates
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Enumeration Date | 01/14/2013
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Last Update Date | 05/20/2016
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Provider Practice Location Address
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Address Line | 6840 VIRGINIA PKWY SUITE 130
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City | MCKINNEY
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State | TX
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Zip | 75071-5516
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Country | US
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Telephone | 972-562-7999
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Fax |
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Provider Business Mailing Address
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Address Line | 6840 VIRGINIA PKWY SUITE 130
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City | MCKINNEY
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State | TX
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Zip | 75071-5516
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Country | US
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Telephone | 972-562-7999
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Fax |
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Authorized Official
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Title or Position | GENERAL DENTIST/OWNER
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Name | MICHAEL BOLTEN
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Credential | D.D.S.
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Telephone | 972-562-7999
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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 | 25399
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 21014
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License Number State | TX
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