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General NPI Number Information
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NPI Number | 1366259897
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Entity Type | Organization
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Legal Business Name | VISTA ORTHODONTIC GROUP LLC
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Dates
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Enumeration Date | 12/17/2024
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Last Update Date | 12/17/2024
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Provider Practice Location Address
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Address Line | 400 SW BOND ST STE 300
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City | BEND
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State | OR
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Zip | 97702-3798
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Country | US
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Telephone | 541-848-6642
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Fax | 541-848-6642
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Provider Business Mailing Address
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Address Line | 400 SW BOND ST STE 300
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City | BEND
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State | OR
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Zip | 97702-3798
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Country | US
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Telephone | 541-848-6642
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Fax | 541-848-6649
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Authorized Official
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Title or Position | OWNER/ORTHODONTIST
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Name | BLAIR H STRUBLE
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Credential | DMD, MSD
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Telephone | 541-848-6642
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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