Provider Demographics
NPI:1194542928
Name:MAGNOLIA LANE GA PARTNERS LLC
Entity type:Organization
Organization Name:MAGNOLIA LANE GA PARTNERS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DELASH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MPH, MBA, D AB
Authorized Official - Phone:770-336-7074
Mailing Address - Street 1:1235 ROBINSON RD STE H
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-3832
Mailing Address - Country:US
Mailing Address - Phone:770-487-1880
Mailing Address - Fax:770-487-1851
Practice Address - Street 1:1235 ROBINSON RD STE H
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3832
Practice Address - Country:US
Practice Address - Phone:770-487-1880
Practice Address - Fax:770-487-1851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-23
Last Update Date:2025-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Multi-Specialty