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General NPI Number Information
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NPI Number | 1699277228
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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 | 02/28/2018
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Last Update Date | 02/28/2018
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Provider Practice Location Address
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Address Line | 507 N 3RD ST
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City | MABANK
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State | TX
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Zip | 75147-8328
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Country | US
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Telephone | 903-603-4406
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Fax | 903-201-6787
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Provider Business Mailing Address
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Address Line | 507 N 3RD ST
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City | MABANK
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State | TX
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Zip | 75147-8328
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Country | US
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Telephone | 903-603-4406
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Fax | 903-201-6787
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Authorized Official
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Title or Position | DENTIST
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Name | DR. GERARD THOMAS MACY
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Credential | DDS
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Telephone | 903-603-4406
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 22174
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License Number State | TX
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