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General NPI Number Information
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NPI Number | 1134540628
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Entity Type | Organization
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Legal Business Name | EAGLE DENTAL CENTER OF TEXARKANA PLLC
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Dates
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Enumeration Date | 12/30/2013
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Last Update Date | 06/04/2020
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Provider Practice Location Address
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Address Line | 4009 MOORES LN
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City | TEXARKANA
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State | TX
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Zip | 75503
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Country | US
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Telephone | 903-794-9974
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Fax | 903-793-6067
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Provider Business Mailing Address
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Address Line | 4009 MOORES LN
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City | TEXARKANA
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State | TX
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Zip | 75503
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Country | US
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Telephone | 903-794-9974
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Fax | 903-793-6067
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Authorized Official
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Title or Position | CLINIC ADMINISTRATOR
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Name | AMANDA MIOT
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Credential |
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Telephone | 903-794-9974
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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 |
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License Number State |
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