Provider Demographics
NPI:1558536706
Name:MAGNOLIA DENTAL
Entity Type:Organization
Organization Name:MAGNOLIA DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:C
Authorized Official - Last Name:COLLAZO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:954-227-1417
Mailing Address - Street 1:9625 WESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-2513
Mailing Address - Country:US
Mailing Address - Phone:954-227-1417
Mailing Address - Fax:954-227-0197
Practice Address - Street 1:9625 WESTVIEW DR
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33076-2513
Practice Address - Country:US
Practice Address - Phone:954-227-1417
Practice Address - Fax:954-227-0197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0012295122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty