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General NPI Number Information
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NPI Number | 1033479126
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Entity Type | Organization
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Legal Business Name | CREST DENTAL LLC
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Dates
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Enumeration Date | 05/22/2012
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Last Update Date | 05/22/2012
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Provider Practice Location Address
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Address Line | 1354 W ARMY TRAIL RD
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City | CAROL STREAM
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State | IL
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Zip | 60188-4836
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Country | US
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Telephone | 847-361-2400
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Fax | 630-289-6870
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Provider Business Mailing Address
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Address Line | 1354 W ARMY TRAIL RD
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City | CAROL STREAM
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State | IL
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Zip | 60188-4836
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. AMI K SHAH
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Credential | D.D.S
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Telephone | 847-361-2400
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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 | 019.027379
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License Number State | IL
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