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General NPI Number Information
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NPI Number | 1689182842
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Entity Type | Organization
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Legal Business Name | MYOLOGY OROFACIAL THERAPY LLC
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Dates
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Enumeration Date | 01/22/2018
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Last Update Date | 08/11/2021
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Provider Practice Location Address
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Address Line | 44 OLD RIDGEFIELD RD
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City | WILTON
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State | CT
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Zip | 06897-3055
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Country | US
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Telephone | 203-451-3780
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Fax |
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Provider Business Mailing Address
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Address Line | 250 THUNDER LAKE RD
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City | WILTON
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State | CT
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Zip | 06897-1339
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Country | US
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Telephone | 203-451-3780
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Fax |
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Authorized Official
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Title or Position | CERTIFIED OROFACIAL MYOLOGIST
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Name | MRS. SUSAN MARIE QUARANTA
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Credential | RDH, MS, COM
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Telephone | 203-451-3780
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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 | 005750
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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