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General NPI Number Information
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NPI Number | 1316300460
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Entity Type | Organization
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Legal Business Name | RIVERSIDE FAMILY DENTAL CARE, INC
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Dates
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Enumeration Date | 04/05/2016
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Last Update Date | 04/05/2016
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Provider Practice Location Address
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Address Line | 1614 W 700 N
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City | SALT LAKE CITY
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State | UT
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Zip | 84116
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Country | US
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Telephone | 385-229-4222
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Fax | 801-883-9276
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Provider Business Mailing Address
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Address Line | 1614 W 700 N
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City | SALT LAKE CITY
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State | UT
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Zip | 84116
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Country | US
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Telephone | 385-229-4222
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Fax | 801-883-9276
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Authorized Official
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Title or Position | DENTIST/PRESIDENT
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Name | DR. TIMOTHY ANGER
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Credential | D.M.D.
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Telephone | 385-229-4222
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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 | 4923760
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License Number State | UT
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