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General NPI Number Information
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NPI Number | 1699919183
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Entity Type | Individual
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Provider Name | MARK WILLAM BANTZ DDS
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Gender | Male
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Dates
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Enumeration Date | 04/28/2009
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Last Update Date | 04/28/2009
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Provider Practice Location Address
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Address Line | 820 E COLFAX AVE
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City | SOUTH BEND
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State | IN
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Zip | 46617-2804
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Country | US
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Telephone | 574-234-4117
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Fax | 574-289-3631
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Provider Business Mailing Address
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Address Line | 820 E COLFAX AVE
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City | SOUTH BEND
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State | IN
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Zip | 46617-2804
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Country | US
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Telephone | 574-234-4117
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Fax | 574-289-3631
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 7086
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License Number State | IN
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