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General NPI Number Information
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NPI Number | 1588355267
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Entity Type | Organization
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Legal Business Name | ENCHANTED LAKE DENTAL LLC
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Dates
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Enumeration Date | 05/15/2023
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Last Update Date | 05/15/2023
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Provider Practice Location Address
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Address Line | 1058 KEOLU DR STE B104
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City | KAILUA
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State | HI
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Zip | 96734-3844
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Country | US
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Telephone | 808-261-6767
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Fax |
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Provider Business Mailing Address
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Address Line | 1058 KEOLU DR STE B104
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City | KAILUA
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State | HI
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Zip | 96734-3844
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Country | US
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Telephone | 808-261-6767
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JUSTIN SJULSON
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Credential | DDS
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Telephone | 952-353-0411
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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 |
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License Number State |
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