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General NPI Number Information
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NPI Number | 1174673222
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Entity Type | Individual
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Provider Name | BRYAN REED MEDARIS D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 01/11/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 4411 E FLAMINGO AVE
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City | NAMPA
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State | ID
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Zip | 83687-3113
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Country | US
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Telephone | 208-466-3597
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Fax | 208-466-8147
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Provider Business Mailing Address
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Address Line | 12231 W CARIBEE INLET DR
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City | STAR
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State | ID
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Zip | 83669-5653
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Country | US
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Telephone | 208-286-0470
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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 | D-3814
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License Number State | ID
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