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General NPI Number Information
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NPI Number | 1184061582
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Entity Type | Organization
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Legal Business Name | ABOUT SMILES DENTAL, LLC
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Dates
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Enumeration Date | 05/27/2013
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Last Update Date | 05/28/2013
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Provider Practice Location Address
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Address Line | 4575 23RD AVE S STE 1200
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City | FARGO
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State | ND
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Zip | 58104-8784
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Country | US
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Telephone | 701-356-4077
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Fax | 701-356-2108
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Provider Business Mailing Address
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Address Line | 4575 23RD AVE S STE 1200
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City | FARGO
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State | ND
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Zip | 58104-8784
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Country | US
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Telephone | 701-356-4077
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Fax | 701-356-2108
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Authorized Official
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Title or Position | OWNER
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Name | DR. SVETLANA KONSTANTINOVNA SAMPSON
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Credential | DDS
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Telephone | 214-790-5151
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 2105
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License Number State | ND
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