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General NPI Number Information
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NPI Number | 1184989584
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Entity Type | Organization
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Legal Business Name | TEAM DENTAL FAMILY DENTISTRY LLC
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Dates
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Enumeration Date | 07/11/2012
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Last Update Date | 07/11/2012
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Provider Practice Location Address
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Address Line | 507 E 83RD ST
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City | CHICAGO
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State | IL
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Zip | 60619-5002
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Country | US
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Telephone | 773-783-8326
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Fax | 773-783-7985
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Provider Business Mailing Address
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Address Line | PO BOX 15219
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City | CHICAGO
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State | IL
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Zip | 60615-5140
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Country | US
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Telephone | 773-783-8326
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Fax |
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Authorized Official
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Title or Position | MANAGING PARTNER
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Name | DR. REGINALD T BAKER
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Credential | D.D.S
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Telephone | 773-783-8326
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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 | 019025166
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License Number State | IL
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