Provider Demographics
NPI:1871839464
Name:MAGNUSON DENTAL GROUP, PC
Entity Type:Organization
Organization Name:MAGNUSON DENTAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGNUSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:978-468-7746
Mailing Address - Street 1:205 WILLOW ST
Mailing Address - Street 2:BUILDING B
Mailing Address - City:SOUTH HAMILTON
Mailing Address - State:MA
Mailing Address - Zip Code:01982-2255
Mailing Address - Country:US
Mailing Address - Phone:978-468-7746
Mailing Address - Fax:
Practice Address - Street 1:205 WILLOW ST
Practice Address - Street 2:BUILDING B
Practice Address - City:SOUTH HAMILTON
Practice Address - State:MA
Practice Address - Zip Code:01982-2255
Practice Address - Country:US
Practice Address - Phone:978-468-7746
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-31
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA209421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty