Provider Demographics
NPI:1164502332
Name:MAGNOLIA DENTAL CORPORATION PC
Entity Type:Organization
Organization Name:MAGNOLIA DENTAL CORPORATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARDS
Authorized Official - Middle Name:RUDD
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:540-943-2723
Mailing Address - Street 1:400 SOUTH MAGNOLIA AVENUE
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:VA
Mailing Address - Zip Code:22980
Mailing Address - Country:US
Mailing Address - Phone:540-943-2723
Mailing Address - Fax:540-943-1419
Practice Address - Street 1:400 SOUTH MAGNOLIA AVENUE
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:VA
Practice Address - Zip Code:22980
Practice Address - Country:US
Practice Address - Phone:540-943-2723
Practice Address - Fax:540-943-1419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
201253OtherANTHEM
201256OtherANTHEM
1354201OtherUNITED CONCORDIA