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General NPI Number Information
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NPI Number | 1124013982
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Entity Type | Individual
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Provider Name | JAMES EDWARD BLOOD D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 09/16/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 375 DENTAL SQUADRON 310 W. LOSEY ST.
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City | DENTAL SQUADRON
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State | IN
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Zip | 62225
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Country | US
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Telephone | 618-256-2750
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Fax |
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Provider Business Mailing Address
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Address Line | 162 KNOB CREEK LN
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City | O FALLON
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State | IL
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Zip | 62269-6618
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Country | US
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Telephone | 618-632-1971
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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 | 019-20940
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License Number State | IL
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