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General NPI Number Information
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NPI Number | 1588905384
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Entity Type | Organization
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Legal Business Name | DOCTOR'S DENTAL GROUP
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Dates
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Enumeration Date | 03/05/2013
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Last Update Date | 03/05/2013
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Provider Practice Location Address
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Address Line | 3850 COCONUT CREEK PKWY STE C
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City | COCONUT CREEK
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State | FL
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Zip | 33066-1600
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Country | US
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Telephone | 954-917-7600
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Fax |
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Provider Business Mailing Address
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Address Line | 3850 COCONUT CREEK PKWY STE C
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City | COCONUT CREEK
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State | FL
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Zip | 33066-1600
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Country | US
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Telephone | 954-917-7600
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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. RAUL LIZASO
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Credential | D.M.D
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Telephone | 954-917-7600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 126800000X
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Taxonomy Name | Dental Assistant
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License Number |
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License Number State |
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Taxonomy #3
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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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