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General NPI Number Information
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NPI Number | 1083170021
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Entity Type | Organization
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Legal Business Name | SOUL DENTAL WEST PLLC
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Dates
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Enumeration Date | 02/14/2019
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Last Update Date | 02/14/2019
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Provider Practice Location Address
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Address Line | 853 11TH AVE
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City | NEW YORK
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State | NY
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Zip | 10019
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Country | US
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Telephone | 212-201-0718
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Fax | 646-597-6068
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Provider Business Mailing Address
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Address Line | 853 11TH AVE
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City | NEW YORK
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State | NY
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Zip | 10019
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Country | US
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Telephone | 212-201-0718
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Fax | 646-597-6068
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | ALLA MALANITCHEVA
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Credential |
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Telephone | 718-916-6748
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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 |
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License Number State |
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