Provider Demographics
NPI:1043533623
Name:MAGNOLIA FAMILY DENTISTRY OF COLUMBUS, INC.
Entity type:Organization
Organization Name:MAGNOLIA FAMILY DENTISTRY OF COLUMBUS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DONNIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-328-8001
Mailing Address - Street 1:2401 5TH ST N STE 2
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2005
Mailing Address - Country:US
Mailing Address - Phone:662-328-8001
Mailing Address - Fax:888-852-8644
Practice Address - Street 1:2401 5TH ST N STE 2
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2005
Practice Address - Country:US
Practice Address - Phone:662-328-8001
Practice Address - Fax:888-852-8644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3463-081223G0001X
MS1860-791223G0001X
MS3160-001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02150825Medicaid