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General NPI Number Information
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NPI Number | 1285533745
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Entity Type | Organization
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Legal Business Name | LAREDO ORAL MAXILLOFACIAL SURGERY LLC
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Dates
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Enumeration Date | 11/02/2026
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Last Update Date | 11/02/2026
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Provider Practice Location Address
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Address Line | 220 W HILLSIDE RD STE 1
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City | LAREDO
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State | TX
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Zip | 78041-6903
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Country | US
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Telephone | 435-512-3442
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Fax | 210-490-3512
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Provider Business Mailing Address
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Address Line | 504 CORDILLERA TRCE
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City | BOERNE
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State | TX
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Zip | 78006-5777
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Country | US
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Telephone | 435-512-3442
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Fax | 210-490-3512
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Authorized Official
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Title or Position | OWNER
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Name | DR. JUSTIN ERIC OLSEN
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Credential | DDS
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Telephone | 435-512-3442
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number |
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License Number State |
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