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General NPI Number Information
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NPI Number | 1093141053
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Entity Type | Organization
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Legal Business Name | WESTGROVE DENTAL CENTER
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Dates
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Enumeration Date | 09/23/2013
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Last Update Date | 09/23/2013
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Provider Practice Location Address
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Address Line | 519 N CASS AVE STE 102
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City | WESTMONT
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State | IL
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Zip | 60559-1514
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Country | US
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Telephone | 630-389-0006
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Fax | 630-442-7216
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Provider Business Mailing Address
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Address Line | 519 N CASS AVE STE 102
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City | WESTMONT
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State | IL
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Zip | 60559-1514
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Country | US
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Telephone | 630-389-0006
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Fax | 630-442-7216
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MS. LAURA FUNKE
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Credential |
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Telephone | 630-389-0006
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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 | 019027777
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License Number State | IL
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