MEDICARE: MAGICO DENTAL PLLC

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	122300000X	Dentist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	34745052	OTHER	TX	DRIVERS LICENSE

General Provider Information

NPI Number	:	1124511365
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGICO DENTAL PLLC

Provider Business Mailing Address
First Line	:	900 S WAYSIDE DR STE 100
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77023-3418
Country	:	US
Telephone Number	:	832-203-7968
Fax Number	:

Provider Business Practice Location Address
First Line	:	5803 LYONS AVE
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77020-4833
Country	:	US
Telephone Number	:	281-974-3996
Fax Number	:

Authorized Official
Title or Position	:	BILLING DIRECTOR
Name	:	MISS NELI GUEVARA
Credential	:
Telephone Number	:	281-974-3996

Provider Enumeration Date	:	06/12/2018
Last Update Date	:	06/16/2018

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Directions to “MAGICO DENTAL PLLC ” Practice Location

Language	Start Address	Practice Location

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