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General NPI Number Information
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NPI Number | 1326298753
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Entity Type | Individual
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Provider Name | SAMANTA ANDISCO D.M.D.
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Gender | Female
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Dates
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Enumeration Date | 09/23/2008
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Last Update Date | 05/01/2018
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Provider Practice Location Address
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Address Line | 19240 QUESADA AVE
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City | PORT CHARLOTTE
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State | FL
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Zip | 33948-3126
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Country | US
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Telephone | 941-743-7435
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Fax | 941-743-7429
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Provider Business Mailing Address
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Address Line | 9500 BONITA BEACH RD SE STE 301
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City | BONITA SPRINGS
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State | FL
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Zip | 34135-4698
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Country | US
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Telephone | 239-319-2440
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Fax | 239-319-2440
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | DN17588
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License Number State | FL
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