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General NPI Number Information
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NPI Number | 1396158986
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Entity Type | Individual
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Provider Name | MICHAEL RICHARD SHELESTAK DMD
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Gender | Male
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Dates
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Enumeration Date | 06/11/2014
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Last Update Date | 04/09/2021
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Provider Practice Location Address
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Address Line | 3115 MAIN ST
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City | WEST MIDDLESEX
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State | PA
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Zip | 16159-3411
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Country | US
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Telephone | 724-528-1515
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Fax | 724-528-0217
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Provider Business Mailing Address
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Address Line | PO BOX 636896
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City | CINCINNATI
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State | OH
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Zip | 45263-6896
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Country | US
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Telephone | 330-884-7158
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Fax | 330-884-7175
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | DS040096
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | FS4701428
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License Number State | PA
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Taxonomy #3
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 30024581
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License Number State | OH
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