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General NPI Number Information
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NPI Number | 1265472047
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Entity Type | Organization
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Legal Business Name | SYNERGY DENTAL, PLLC
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Dates
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Enumeration Date | 06/08/2006
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Last Update Date | 03/25/2010
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Provider Practice Location Address
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Address Line | 228 WEST CAMPBELL ROAD
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City | RICHARDSON
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State | TX
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Zip | 75080-3512
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Country | US
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Telephone | 972-633-2377
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Fax | 972-633-2388
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Provider Business Mailing Address
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Address Line | 228 WEST CAMPBELL ROAD
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City | RICHARDSON
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State | TX
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Zip | 75080-3512
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Country | US
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Telephone | 972-633-2377
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Fax | 972-633-2388
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Authorized Official
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Title or Position | DENTIST
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Name | DR. KOMSON SUDHIVORASETH
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Credential | D.D.S.
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Telephone | 972-633-2377
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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 | 20761
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License Number State | TX
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