MEDICARE: CENTRAL AVENUE DENTISTRY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1407504186
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL AVENUE DENTISTRY LLC

Provider Business Mailing Address
First Line	:	2901 CENTRAL AVE
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35209-2505
Country	:	US
Telephone Number	:	205-870-1363
Fax Number	:

Provider Business Practice Location Address
First Line	:	2901 CENTRAL AVE
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35209-2505
Country	:	US
Telephone Number	:	205-870-1363
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	CHELSEA ASHWORTH MANISCALCO
Credential	:	DMD
Telephone Number	:	205-870-1363

Provider Enumeration Date	:	03/12/2022
Last Update Date	:	03/28/2022

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