Provider Demographics
NPI:1598545386
Name:SOUTHERN MAGNOLIA DENTISTRY, LLC
Entity Type:Organization
Organization Name:SOUTHERN MAGNOLIA DENTISTRY, LLC
Other - Org Name:SOUTHERN MAGNOLIA DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AKEELE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON-VALLOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-229-3121
Mailing Address - Street 1:3215 MASONIC DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-4246
Mailing Address - Country:US
Mailing Address - Phone:318-229-3121
Mailing Address - Fax:
Practice Address - Street 1:3215 MASONIC DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-4246
Practice Address - Country:US
Practice Address - Phone:318-229-3121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-29
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty