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General NPI Number Information
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NPI Number | 1740169630
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Entity Type | Individual
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Provider Name | GAVIN SHIBLI TARAZI DMD
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Gender | Male
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Dates
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Enumeration Date | 08/27/2025
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Last Update Date | 08/27/2025
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Provider Practice Location Address
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Address Line | 11941 MANCHESTER RD
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City | DES PERES
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State | MO
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Zip | 63131-4502
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Country | US
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Telephone | 314-501-8300
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Fax |
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Provider Business Mailing Address
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Address Line | 303 E 3RD ST APT A
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City | ALTON
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State | IL
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Zip | 62002-2407
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Country | US
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Telephone | 815-382-7291
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Fax |
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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 | 2025036865
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License Number State | MO
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