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General NPI Number Information
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NPI Number | 1699047670
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Entity Type | Organization
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Legal Business Name | DENTAL GROUP OF MENTOR
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Dates
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Enumeration Date | 02/06/2012
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Last Update Date | 02/06/2012
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Provider Practice Location Address
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Address Line | 9571 MENTOR AVE
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City | MENTOR
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State | OH
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Zip | 44060-4521
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Country | US
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Telephone | 440-352-5700
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Fax | 440-352-5721
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Provider Business Mailing Address
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Address Line | 9571 MENTOR AVE
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City | MENTOR
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State | OH
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Zip | 44060-4521
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Country | US
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Telephone | 440-352-5700
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Fax | 440-352-5721
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Authorized Official
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Title or Position | OWNER
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Name | DR. JONATHAN JAY KLINEMAN
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Credential |
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Telephone | 440-352-5700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 30021252
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License Number State | OH
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