MEDICARE: GENESIS DENTAL GROUP HOMEWOOD P.C.

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	6138	AL

General Provider Information

NPI Number	:	1528577129
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENESIS DENTAL GROUP HOMEWOOD P.C.

Provider Business Mailing Address
First Line	:	3150 ZELDA CT
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36106-2607
Country	:	US
Telephone Number	:	334-676-2320
Fax Number	:

Provider Business Practice Location Address
First Line	:	2045 BROOKWOOD MEDICAL CTR DR STE 4
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35209-6809
Country	:	US
Telephone Number	:	205-871-6600
Fax Number	:	205-871-6680

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	PAT HOLT
Credential	:
Telephone Number	:	334-676-2320

Provider Enumeration Date	:	09/26/2017
Last Update Date	:	09/26/2017

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