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General NPI Number Information
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NPI Number | 1881922466
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Entity Type | Organization
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Legal Business Name | MAGNOLIA FAMILY DENTISTRY, LLC
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Dates
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Enumeration Date | 11/19/2009
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Last Update Date | 11/19/2009
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Provider Practice Location Address
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Address Line | 513 W COMMERCE ST
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City | ABERDEEN
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State | MS
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Zip | 39730-2543
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Country | US
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Telephone | 662-369-2063
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Fax | 662-369-2076
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Provider Business Mailing Address
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Address Line | 513 W COMMERCE ST
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City | ABERDEEN
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State | MS
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Zip | 39730-2543
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Country | US
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Telephone | 662-369-2063
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Fax | 662-369-2076
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Authorized Official
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Title or Position | MBR
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Name | DR. ROGER A WRIGHT
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Credential | DMD
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Telephone | 662-369-2063
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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 | 3463-08
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 1860-79
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License Number State | MS
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