Provider Demographics
NPI:1235610882
Name:MAGIC DENTAL CAMDEN, LLC
Entity Type:Organization
Organization Name:MAGIC DENTAL CAMDEN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATALYA
Authorized Official - Middle Name:
Authorized Official - Last Name:KONDRATYEVA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:856-963-0315
Mailing Address - Street 1:433 MARKET ST STE 102
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08102-1572
Mailing Address - Country:US
Mailing Address - Phone:856-963-2369
Mailing Address - Fax:856-963-2369
Practice Address - Street 1:433 MARKET ST STE 102
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08102-1572
Practice Address - Country:US
Practice Address - Phone:856-963-2369
Practice Address - Fax:856-963-2369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-22
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI020184001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0617415Medicaid