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General NPI Number Information
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NPI Number | 1700931037
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Entity Type | Organization
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Legal Business Name | ASSOCIATES OF FAMILY DENTISTRY
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Dates
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Enumeration Date | 01/25/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 549 SOUTH MAIN ST
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City | CLEVELAND
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State | GA
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Zip | 30528
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Country | US
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Telephone | 706-865-2248
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Fax | 706-219-2051
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Provider Business Mailing Address
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Address Line | PO BOX 870
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City | CLEVELAND
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State | GA
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Zip | 30528-0016
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Country | US
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Telephone | 706-865-2248
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Fax | 706-219-2051
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Authorized Official
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Title or Position | CEO
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Name | DR. EDWARD H WALL
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Credential | DMD
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Telephone | 706-865-2248
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN011027
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License Number State | GA
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