Provider Demographics
NPI:1104717560
Name:SOUTHERN MAGNOLIA DENTAL LLC
Entity type:Organization
Organization Name:SOUTHERN MAGNOLIA DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PFISTER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:334-232-0550
Mailing Address - Street 1:2660 MONTGOMERY HWY STE 2
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-2618
Mailing Address - Country:US
Mailing Address - Phone:334-232-0550
Mailing Address - Fax:334-232-0488
Practice Address - Street 1:2660 MONTGOMERY HWY STE 2
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-2618
Practice Address - Country:US
Practice Address - Phone:334-232-0550
Practice Address - Fax:334-232-0488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-14
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty