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General NPI Number Information
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NPI Number | 1619091568
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Entity Type | Organization
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Legal Business Name | SOUTHERN OHIO ENDODONTICS CLINIC, LLC
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Dates
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Enumeration Date | 03/18/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 31 N PLAZA BLVD
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City | CHILLICOTHEE
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State | OH
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Zip | 45601-1759
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Country | US
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Telephone | 740-774-6230
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Fax | 740-774-6326
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Provider Business Mailing Address
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Address Line | 31 N PLAZA BLVD
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City | CHILLICOTHEE
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State | OH
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Zip | 45601-1759
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Country | US
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Telephone | 740-774-6230
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Fax | 740-774-6326
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Authorized Official
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Title or Position | PRESIDENT
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Name | DERON REISMAN
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Credential |
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Telephone | 740-774-6230
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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 | 20157
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License Number State | OH
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