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General NPI Number Information
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NPI Number | 1790275840
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Entity Type | Organization
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Legal Business Name | MAGIC CITY DENTISTRY, PC
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Dates
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Enumeration Date | 05/15/2018
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Last Update Date | 05/15/2018
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Provider Practice Location Address
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Address Line | 2117 1ST AVE N
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City | BIRMINGHAM
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State | AL
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Zip | 35203-4201
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Country | US
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Telephone | 205-238-6800
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Fax |
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Provider Business Mailing Address
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Address Line | 2816 COLUMBIANA RD
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City | VESTAVIA HILLS
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State | AL
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Zip | 35216-2518
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Country | US
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Telephone | 205-823-3223
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATIVE ASSISTANT
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Name | AINSLEE BOSWELL
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Credential |
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Telephone | 205-823-3223
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 4659
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License Number State | AL
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