=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891351094
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGNOLIA FAMILY DENTISTRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2019
-----------------------------------------------------
Last Update Date | 05/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 402 FOX GLEN CT
-----------------------------------------------------
City | BARRINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60010-1824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-381-5654
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 402 FOX GLEN CT
-----------------------------------------------------
City | BARRINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60010-1824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-381-5654
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INSURANCE MANAGER
-----------------------------------------------------
Name | KRISTY WOLTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-339-3972
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------