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General NPI Number Information
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NPI Number | 1134376189
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Entity Type | Organization
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Legal Business Name | WESTLAKE DENTAL CENTER
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Dates
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Enumeration Date | 08/21/2008
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Last Update Date | 08/21/2008
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Provider Practice Location Address
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Address Line | 214 WASHINGTON ST
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City | INGLESIDE
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State | IL
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Zip | 60041-9208
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Country | US
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Telephone | 847-587-3020
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Fax | 847-587-1598
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Provider Business Mailing Address
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Address Line | 214 WASHINGTON ST
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City | INGLESIDE
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State | IL
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Zip | 60041-9208
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Country | US
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Telephone | 847-587-3020
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Fax | 847-587-1598
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Authorized Official
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Title or Position | OWNER
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Name | DR. MIN J KWON
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Credential | D.D.S.
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Telephone | 847-587-3020
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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 | 019026900
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019025326
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License Number State | IL
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