Provider Demographics
NPI:1053865329
Name:MAGNOLIA FAMILY DENTAL, PLLC
Entity Type:Organization
Organization Name:MAGNOLIA FAMILY DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GARNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-783-2361
Mailing Address - Street 1:4358 LINCOLN ROAD EXT STE 20
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3275
Mailing Address - Country:US
Mailing Address - Phone:601-271-8710
Mailing Address - Fax:
Practice Address - Street 1:215 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:MS
Practice Address - Zip Code:39652-2827
Practice Address - Country:US
Practice Address - Phone:601-783-2361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-04
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty