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General NPI Number Information
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NPI Number | 1730329509
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Entity Type | Organization
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Legal Business Name | FLORIDA INSTITUTE OF OROFACIAL MYOLOGY, LLC
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Dates
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Enumeration Date | 03/05/2009
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Last Update Date | 03/05/2009
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Provider Practice Location Address
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Address Line | 3930 S NOVA RD
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City | PORT ORANGE
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State | FL
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Zip | 32127-9281
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Country | US
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Telephone | 386-846-8956
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Fax | 603-687-4663
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Provider Business Mailing Address
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Address Line | 6059 SABAL CREEK BLVD
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City | PORT ORANGE
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State | FL
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Zip | 32128-7136
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Country | US
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Telephone | 386-846-8956
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Fax | 603-687-4663
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Authorized Official
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Title or Position | OWNER
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Name | MS. BETH A THOMPSON
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Credential | RDH, MFT
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Telephone | 386-846-8956
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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 | 8897
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License Number State | MA
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