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General NPI Number Information
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NPI Number | 1336654102
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Entity Type | Organization
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Legal Business Name | ELITE ENDODONTICS
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Dates
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Enumeration Date | 12/02/2017
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Last Update Date | 12/02/2017
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Provider Practice Location Address
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Address Line | 1135 S LAPEER RD STE A
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City | LAKE ORION
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State | MI
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Zip | 48360-1432
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Country | US
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Telephone | 616-502-2846
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Fax |
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Provider Business Mailing Address
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Address Line | 6965 OAKHURST RIDGE RD
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City | CLARKSTON
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State | MI
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Zip | 48348-5053
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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 | ENDODONTIST
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Name | DR. DREW WAYNE MOELLER
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Credential | DDS, MS
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Telephone | 616-502-2846
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 2901020373
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License Number State | MI
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