Provider Demographics
NPI:1689746281
Name:PEDRAZA, MAGNOLIA (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:MAGNOLIA
Middle Name:
Last Name:PEDRAZA
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 W WEAVER RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:FORSYTH
Mailing Address - State:IL
Mailing Address - Zip Code:62535-9762
Mailing Address - Country:US
Mailing Address - Phone:217-876-0547
Mailing Address - Fax:217-876-0601
Practice Address - Street 1:241 W WEAVER RD
Practice Address - Street 2:SUITE 220
Practice Address - City:FORSYTH
Practice Address - State:IL
Practice Address - Zip Code:62535-9762
Practice Address - Country:US
Practice Address - Phone:217-876-0547
Practice Address - Fax:217-876-0601
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.001709 019.022721223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics