Provider Demographics
NPI:1316671688
Name:MAGNOLIA GREEN DENTAL CARE, P.A.
Entity type:Organization
Organization Name:MAGNOLIA GREEN DENTAL CARE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-923-3802
Mailing Address - Street 1:1 N DALE MABRY HWY STE 605
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-2781
Mailing Address - Country:US
Mailing Address - Phone:813-692-2224
Mailing Address - Fax:813-200-3400
Practice Address - Street 1:6975 PROFESSIONAL PKWY STE B
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34240-8430
Practice Address - Country:US
Practice Address - Phone:941-240-2750
Practice Address - Fax:863-808-0589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty