Provider Demographics
NPI:1043797152
Name:MAGNOLIA DENTAL, LLC
Entity Type:Organization
Organization Name:MAGNOLIA DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:L
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-485-5463
Mailing Address - Street 1:10208 LAKE ARBOR WAY
Mailing Address - Street 2:
Mailing Address - City:MITCHELLVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-3113
Mailing Address - Country:US
Mailing Address - Phone:301-485-5463
Mailing Address - Fax:
Practice Address - Street 1:10208 LAKE ARBOR WAY
Practice Address - Street 2:
Practice Address - City:MITCHELLVILLE
Practice Address - State:MD
Practice Address - Zip Code:20721
Practice Address - Country:US
Practice Address - Phone:301-485-5463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-21
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty