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General NPI Number Information
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NPI Number | 1366956419
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Entity Type | Organization
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Legal Business Name | BRADLEY M STEWART DMD LLC
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Dates
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Enumeration Date | 11/28/2017
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Last Update Date | 11/28/2017
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Provider Practice Location Address
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Address Line | 6855 CRUMPLER BLVD STE 100
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-1930
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Country | US
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Telephone | 901-262-0217
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Fax |
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Provider Business Mailing Address
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Address Line | 6855 CRUMPLER BLVD STE 100
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-1930
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Country | US
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Telephone | 901-262-0217
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. BRADLEY MITCHELL STEWART
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Credential | DMD
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Telephone | 901-262-0217
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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 | 3105-99
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License Number State | MS
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