MEDICARE: MAGIC CITY DENTISTRY, 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	261QD0000X	Dental Clinic/Center	4659	AL

General Provider Information

NPI Number	:	1790275840
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGIC CITY DENTISTRY, PC

Provider Business Mailing Address
First Line	:	2816 COLUMBIANA RD
Second Line	:
City	:	VESTAVIA HILLS
State	:	AL
Zip	:	35216-2518
Country	:	US
Telephone Number	:	205-823-3223
Fax Number	:

Provider Business Practice Location Address
First Line	:	2117 1ST AVE N
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35203-4201
Country	:	US
Telephone Number	:	205-238-6800
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATIVE ASSISTANT
Name	:	AINSLEE BOSWELL
Credential	:
Telephone Number	:	205-823-3223

Provider Enumeration Date	:	05/15/2018
Last Update Date	:	05/15/2018

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