Provider Demographics
NPI:1104134881
Name:MAGNOLIA DENTAL
Entity type:Organization
Organization Name:MAGNOLIA DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BASOM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:740-775-8050
Mailing Address - Street 1:11 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-8603
Mailing Address - Country:US
Mailing Address - Phone:740-775-8050
Mailing Address - Fax:740-775-8053
Practice Address - Street 1:11 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-8603
Practice Address - Country:US
Practice Address - Phone:740-775-8050
Practice Address - Fax:740-775-8053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300226131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty