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General NPI Number Information
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NPI Number | 1275208902
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Entity Type | Organization
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Legal Business Name | HERITAGE DENTAL LLC
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Dates
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Enumeration Date | 08/13/2021
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Last Update Date | 08/13/2021
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Provider Practice Location Address
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Address Line | 5 E JIMMIE LEEDS RD
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City | GALLOWAY
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State | NJ
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Zip | 08205-9705
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Country | US
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Telephone | 609-646-3890
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Fax |
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Provider Business Mailing Address
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Address Line | 5 E JIMMIE LEEDS RD
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City | GALLOWAY
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State | NJ
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Zip | 08205-9705
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Country | US
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Telephone | 609-646-3890
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Fax |
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | MRS. ELENA DR. GUT
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Credential |
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Telephone | 609-646-3890
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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 |
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License Number State |
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