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General NPI Number Information
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NPI Number | 1104215367
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Entity Type | Organization
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Legal Business Name | RESTORE DENTAL PLLC
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Dates
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Enumeration Date | 01/12/2015
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Last Update Date | 01/14/2016
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Provider Practice Location Address
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Address Line | 3108 W STATE HIGHWAY 22
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City | CORSICANA
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State | TX
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Zip | 75110-2435
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Country | US
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Telephone | 903-257-8815
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Fax | 903-900-4184
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Provider Business Mailing Address
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Address Line | 3108 W STATE HIGHWAY 22
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City | CORSICANA
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State | TX
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Zip | 75110-2435
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Country | US
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Telephone | 903-257-8815
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Fax | 903-900-4184
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MAHESH B. GONDI
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Credential | DMD
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Telephone | 903-257-8815
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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 | 22213
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 22213
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License Number State | TX
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