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General NPI Number Information
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NPI Number | 1750506036
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Entity Type | Organization
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Legal Business Name | SLADE DMD CORPORATION
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Dates
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Enumeration Date | 04/13/2007
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Last Update Date | 08/04/2014
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Provider Practice Location Address
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Address Line | 862 MEINECKE AVENUE SUITE 200
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City | SAN LUIS OBISPO
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State | CA
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Zip | 93405
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Country | US
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Telephone | 805-544-7804
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Fax | 805-544-6020
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Provider Business Mailing Address
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Address Line | 862 MEINECKE AVENUE SUITE 200
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City | SAN LUIS OBISPO
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State | CA
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Zip | 93405
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Country | US
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Telephone | 805-544-7804
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Fax | 805-544-6020
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | MR. TROY KENDALL SLADE
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Credential | D.M.D.
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Telephone | 805-544-7804
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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 | 62898
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License Number State | CA
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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 | 58800
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License Number State | CA
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