MEDICARE: MAGNOLIA DENTISTRY, LLC

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	261QD0000X	Dental Clinic/Center	DN1856612	MA

General Provider Information

NPI Number	:	1831691906
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA DENTISTRY, LLC

Provider Business Mailing Address
First Line	:	70 MAIN ST STE 100
Second Line	:
City	:	NORTH ANDOVER
State	:	MA
Zip	:	01845-2587
Country	:	US
Telephone Number	:	978-965-4315
Fax Number	:	978-965-4314

Provider Business Practice Location Address
First Line	:	70 MAIN ST STE 100
Second Line	:
City	:	NORTH ANDOVER
State	:	MA
Zip	:	01845-2427
Country	:	US
Telephone Number	:	617-959-4943
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. YUNJI LEE
Credential	:	DMD
Telephone Number	:	617-959-4943

Provider Enumeration Date	:	03/05/2018
Last Update Date	:	02/18/2020

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