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General NPI Number Information
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NPI Number | 1013276211
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Entity Type | Organization
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Legal Business Name | BAYSTATE DENTAL PC
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Dates
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Enumeration Date | 05/08/2012
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Last Update Date | 05/08/2012
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Provider Practice Location Address
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Address Line | 516 MONTGOMERY ST
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City | CHICOPEE
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State | MA
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Zip | 01020-1469
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Country | US
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Telephone | 413-534-5144
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Fax |
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Provider Business Mailing Address
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Address Line | 1795 MAIN ST SUITE 212
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City | SPRINGFIELD
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State | MA
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Zip | 01103-1077
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Country | US
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Telephone | 413-733-5700
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Fax | 413-439-0563
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Authorized Official
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Title or Position | COO
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Name | DR. MATTHEW J HALUCH
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Credential | DDS
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Telephone | 413-733-5700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN20704
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License Number State | MA
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