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General NPI Number Information
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NPI Number | 1104818467
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Entity Type | Individual
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Provider Name | BEN MICHAEL KOOLICK DDS
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Gender | Male
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Dates
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Enumeration Date | 08/22/2005
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Last Update Date | 04/03/2011
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Provider Practice Location Address
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Address Line | 8390 W CACTUS RD STE 110
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City | PEORIA
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State | AZ
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Zip | 85381-5206
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Country | US
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Telephone | 623-878-3300
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Fax |
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Provider Business Mailing Address
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Address Line | 9494 E DESERT COVE AVE
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City | SCOTTSDALE
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State | AZ
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Zip | 85260-6144
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Country | US
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Telephone | 480-767-1338
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | AZ6037
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License Number State | AZ
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