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General NPI Number Information
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NPI Number | 1154726917
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Entity Type | Organization
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Legal Business Name | COOPER MOUNTAIN DENTAL LLC
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Dates
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Enumeration Date | 10/23/2014
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Last Update Date | 10/23/2014
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Provider Practice Location Address
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Address Line | 11471 SW SCHOLLS FERRY RD
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City | BEAVERTON
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State | OR
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Zip | 97008-7168
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Country | US
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Telephone | 503-356-1078
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Fax |
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Provider Business Mailing Address
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Address Line | 11471 SW SCHOLLS FERRY RD
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City | BEAVERTON
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State | OR
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Zip | 97008-7168
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER DENTIST
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Name | DR. BANU RAMKRISHNA
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Credential | DMD
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Telephone | 503-356-1078
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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 | D8822
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License Number State | OR
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