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General NPI Number Information
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NPI Number | 1205093903
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Entity Type | Organization
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Legal Business Name | MOFFITT DENTAL CENTER
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Dates
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Enumeration Date | 05/20/2008
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Last Update Date | 05/20/2008
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Provider Practice Location Address
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Address Line | 422 W BROADWAY ST
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City | EAGLE GROVE
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State | IA
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Zip | 50533-1704
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Country | US
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Telephone | 515-448-4852
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Fax | 515-448-3533
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Provider Business Mailing Address
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Address Line | 422 W BROADWAY ST
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City | EAGLE GROVE
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State | IA
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Zip | 50533-1704
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Country | US
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Telephone | 515-448-4852
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Fax | 515-448-3533
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Authorized Official
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Title or Position | OWNER/DOCTOR
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Name | DR. MICHAEL WALTER MOFFITT
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Credential | DDS
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Telephone | 515-448-4852
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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 | 6102
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License Number State | IA
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