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General NPI Number Information
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NPI Number | 1114252517
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Entity Type | Individual
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Provider Name | CODY KENT HAAS D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 10/02/2009
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Last Update Date | 10/02/2009
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Provider Practice Location Address
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Address Line | 1639 23RD AVE
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City | LEWISTON
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State | ID
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Zip | 83501-6308
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Country | US
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Telephone | 208-746-0431
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Fax |
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Provider Business Mailing Address
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Address Line | 1639 23RD AVE
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City | LEWISTON
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State | ID
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Zip | 83501-6308
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Country | US
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Telephone | 208-746-0431
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | D-4156
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | DE 60023524
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License Number State | WA
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