Provider Demographics
NPI:1396483871
Name:MAGNOLIA SMILES OF PETAL PLLC
Entity type:Organization
Organization Name:MAGNOLIA SMILES OF PETAL PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OSCAR
Authorized Official - Middle Name:R
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-735-5086
Mailing Address - Street 1:1229 HIGHWAY 42 STE 160-170
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-2733
Mailing Address - Country:US
Mailing Address - Phone:601-735-5086
Mailing Address - Fax:
Practice Address - Street 1:1229 HIGHWAY 42 STE 160-170
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-2733
Practice Address - Country:US
Practice Address - Phone:601-735-5086
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-24
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS200000763Medicaid