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General NPI Number Information
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NPI Number | 1336593110
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Entity Type | Individual
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Provider Name | MONA KHALAJ
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Gender | Female
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Dates
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Enumeration Date | 04/19/2016
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Last Update Date | 04/07/2025
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Provider Practice Location Address
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Address Line | 2015 E EDGEWOOD DR
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City | LAKELAND
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State | FL
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Zip | 33803-3601
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Country | US
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Telephone | 408-202-1014
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Fax |
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Provider Business Mailing Address
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Address Line | 2958 MISSION LAKES DR
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City | LAKELAND
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State | FL
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Zip | 33803-5909
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Country | US
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Telephone |
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Fax |
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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 | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | DN24334
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License Number State | FL
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