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General NPI Number Information
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NPI Number | 1629188172
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Entity Type | Organization
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Legal Business Name | GENESIS DENTAL OF TOOELE, LLC
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Dates
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Enumeration Date | 08/30/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1204 N MAIN ST
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City | TOOELE
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State | UT
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Zip | 84074-9540
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Country | US
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Telephone | 435-882-8600
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Fax | 435-882-8605
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Provider Business Mailing Address
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Address Line | 6087 S REDWOOD RD SUITE C
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City | TAYLORSVILLE
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State | UT
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Zip | 84123-5330
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Country | US
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Telephone | 801-838-8030
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Fax | 801-352-1872
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Authorized Official
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Title or Position | OWNER/MEMBER
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Name | MR. JASON D CASTO
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Credential |
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Telephone | 801-838-8030
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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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