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General NPI Number Information
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NPI Number | 1396868048
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Entity Type | Individual
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Provider Name | DEREK CONKLIN D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/09/2007
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Last Update Date | 02/28/2012
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Provider Practice Location Address
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Address Line | 17471 SHELLEY AVE STE A
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City | SANDY
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State | OR
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Zip | 97055-8084
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Country | US
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Telephone | 503-668-4655
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Fax | 503-668-8755
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Provider Business Mailing Address
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Address Line | 17471 SHELLEY AVE
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City | SANDY
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State | OR
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Zip | 97055-8084
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Country | US
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Telephone | 503-668-4655
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Fax | 503-668-8755
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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 | D8325
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License Number State | OR
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