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General NPI Number Information
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NPI Number | 1508756073
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Entity Type | Organization
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Legal Business Name | 17 EAGLE VILONIA PROFESSIONAL LLC
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Dates
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Enumeration Date | 07/07/2025
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Last Update Date | 07/07/2025
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Provider Practice Location Address
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Address Line | 17 EAGLE PARK DR
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City | VILONIA
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State | AR
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Zip | 72173-9050
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Country | US
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Telephone | 501-796-3903
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Fax |
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Provider Business Mailing Address
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Address Line | 17 EAGLE PARK DR
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City | VILONIA
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State | AR
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Zip | 72173-9050
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Country | US
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Telephone | 501-796-3903
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Fax |
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Authorized Official
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Title or Position | PAYOR RELATIONS
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Name | ASHLEY FORSYTH
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Credential |
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Telephone | 501-796-3903
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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