MEDICARE: MAGNOLIA FAMILY DENTISTRY OF COLUMBUS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	1860-79	MS
2	1223G0001X	General Practice Dentistry	3160-00	MS
3	1223G0001X	General Practice Dentistry	3463-08	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043533623
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA FAMILY DENTISTRY OF COLUMBUS, INC.

Provider Business Mailing Address
First Line	:	2401 5TH ST N STE 2
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39705-2005
Country	:	US
Telephone Number	:	662-328-8001
Fax Number	:	888-852-8644

Provider Business Practice Location Address
First Line	:	2401 5TH ST N STE 2
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39705-2005
Country	:	US
Telephone Number	:	662-328-8001
Fax Number	:	888-852-8644

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	DR. DONNIE J. RICHARDSON JR.
Credential	:	DMD
Telephone Number	:	662-328-8001

Provider Enumeration Date	:	03/10/2010
Last Update Date	:	03/10/2010

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