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General NPI Number Information
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NPI Number | 1669200820
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Entity Type | Individual
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Provider Name | CHANELLE MARIE HOLDER DMD
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Gender | Female
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Dates
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Enumeration Date | 07/22/2024
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Last Update Date | 07/22/2024
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Provider Practice Location Address
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Address Line | 2109 VICTORY BLVD
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City | STATEN ISLAND
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State | NY
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Zip | 10314-6601
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Country | US
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Telephone | 718-494-1300
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Fax |
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Provider Business Mailing Address
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Address Line | 420 E 54TH ST APT 307
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City | NEW YORK
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State | NY
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Zip | 10022-5297
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Country | US
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Telephone | 347-969-1250
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 14166
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License Number State | CT
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