MEDICARE: MAGNOLIA CENTERVILLE 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

General Provider Information

NPI Number	:	1891308011
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA CENTERVILLE LLC

Provider Business Mailing Address
First Line	:	401 MIAMISBURG CENTERVILLE RD
Second Line	:
City	:	CENTERVILLE
State	:	OH
Zip	:	45459-4753
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	401 MIAMISBURG CENTERVILLE RD
Second Line	:
City	:	CENTERVILLE
State	:	OH
Zip	:	45459-4753
Country	:	US
Telephone Number	:	937-435-5073
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF REVENUE CYCLE MANAGEMEN
Name	:	MEGHAN KOENEMAN
Credential	:
Telephone Number	:	380-203-3592

Provider Enumeration Date	:	08/27/2020
Last Update Date	:	09/04/2025

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