Provider Demographics
NPI:1134139371
Name:MAGNOLIA FAMILY DENTISTRY
Entity Type:Organization
Organization Name:MAGNOLIA FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GANIAT
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAWAL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:910-944-1646
Mailing Address - Street 1:121 MAGNOLIA SQUARE CT
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:NC
Mailing Address - Zip Code:28315-2225
Mailing Address - Country:US
Mailing Address - Phone:910-944-1646
Mailing Address - Fax:
Practice Address - Street 1:121 MAGNOLIA SQUARE CT
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:NC
Practice Address - Zip Code:28315-2225
Practice Address - Country:US
Practice Address - Phone:910-944-1646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC73741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty