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General NPI Number Information
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NPI Number | 1457433427
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Entity Type | Individual
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Provider Name | ROBERT L WILLEY D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 10/19/2006
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Last Update Date | 09/03/2008
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Provider Practice Location Address
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Address Line | 71 RIDGECREST DR
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City | MAMMOTH LAKES
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State | CA
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Zip | 93546-0101
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Country | US
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Telephone | 760-920-0542
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Fax | 760-111-1111
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Provider Business Mailing Address
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Address Line | PO BOX 101 PO BOX 101
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City | MAMMOTH LAKES
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State | CA
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Zip | 93546-0101
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Country | US
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Telephone | 760-992-0054
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Fax | 760-111-1111
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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 | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 032414
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License Number State | CA
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