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General NPI Number Information
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NPI Number | 1700029709
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Entity Type | Organization
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Legal Business Name | MID-VALLEY DENTAL ASSOCIATES, LLC
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Dates
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Enumeration Date | 04/07/2009
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Last Update Date | 04/07/2009
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Provider Practice Location Address
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Address Line | 2825 WILLETTA ST SW SUITE A
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City | ALBANY
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State | OR
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Zip | 97321-3846
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Country | US
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Telephone | 541-928-2301
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Fax | 541-928-8493
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Provider Business Mailing Address
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Address Line | 2825 WILLETTA ST SW SUITE A
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City | ALBANY
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State | OR
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Zip | 97321-3846
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Country | US
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Telephone | 541-928-2301
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Fax | 541-928-8493
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | SUSAN M. BAHAM
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Credential |
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Telephone | 541-928-2301
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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 | D8673
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D9084
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D9107
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License Number State | OR
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Taxonomy #4
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D7915
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License Number State | OR
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