# MAGNOLIA DENTAL LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1508684267
- **Authorized official:** MARVIN BLANE JACKSON DDS (OWNER)
- **Authorized official phone:** (435) 637-2100

## Contact information

- **Practice address:** 2346 E BROWN RD, MESA, AZ 85213-5255
- **Practice address phone:** (435) 637-2100
- **Mailing address:** 250 N FAIRGROUNDS RD STE 1, PRICE, UT 84501-4201
- **Mailing address phone:** (435) 637-2100

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QD0000X | Dental Clinic/Center | — | NULL | Yes |

## Other

- **Enumeration date:** 10/01/2024
- **Last updated:** 10/01/2024