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General NPI Number Information
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NPI Number | 1285200782
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Entity Type | Organization
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Legal Business Name | IMAGINE ORTHODONTIC STUDIO PLLC
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Dates
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Enumeration Date | 06/03/2021
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Last Update Date | 06/03/2021
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Provider Practice Location Address
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Address Line | 11502 N 56TH ST
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City | TEMPLE TERRACE
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State | FL
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Zip | 33617-2239
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Country | US
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Telephone | 863-462-4463
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Fax |
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Provider Business Mailing Address
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Address Line | 3595 S FLORIDA AVE
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City | LAKELAND
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State | FL
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Zip | 33803-4860
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Country | US
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Telephone | 863-462-4463
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MICHAEL ANDREW HESS
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Credential | DMD, MS
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Telephone | 727-743-8307
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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