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General NPI Number Information
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NPI Number | 1508196189
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Entity Type | Organization
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Legal Business Name | DENTAL CARE WEST
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Dates
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Enumeration Date | 01/05/2010
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Last Update Date | 01/05/2010
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Provider Practice Location Address
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Address Line | 850 S LATAH ST
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City | BOISE
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State | ID
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Zip | 83705-2255
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Country | US
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Telephone | 208-342-7714
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Fax | 208-342-7781
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Provider Business Mailing Address
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Address Line | 850 S LATAH ST
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City | BOISE
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State | ID
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Zip | 83705-2255
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Country | US
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Telephone | 208-342-7714
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Fax | 208-342-7781
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Authorized Official
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Title or Position | DDS/ OWNER
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Name | MR. CHARLES SCOTT GRACE
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Credential | DDS
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Telephone | 208-342-7714
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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 | D3522
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License Number State | ID
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