MEDICARE: MAGIC SMILE DENTAL PC

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	1223G0001X	General Practice Dentistry	23087	NJ

General Provider Information

NPI Number	:	1497944458
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGIC SMILE DENTAL PC

Provider Business Mailing Address
First Line	:	515 N WOOD AVE
Second Line	:	SUITE 101
City	:	LINDEN
State	:	NJ
Zip	:	07036-4173
Country	:	US
Telephone Number	:	908-486-5000
Fax Number	:	908-486-5006

Provider Business Practice Location Address
First Line	:	515 N WOOD AVE
Second Line	:	SUITE 101
City	:	LINDEN
State	:	NJ
Zip	:	07036-4173
Country	:	US
Telephone Number	:	908-486-5000
Fax Number	:	908-486-5006

Authorized Official
Title or Position	:	OWNER
Name	:	DR. YEFIM KHANIMOV
Credential	:	DDS
Telephone Number	:	908-486-5000

Provider Enumeration Date	:	10/16/2007
Last Update Date	:	10/16/2007

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