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General NPI Number Information
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NPI Number | 1760679005
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Entity Type | Organization
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Legal Business Name | KYLE E PEDERSEN DDS PC
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Dates
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Enumeration Date | 10/01/2007
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Last Update Date | 03/07/2011
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Provider Practice Location Address
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Address Line | 2570 FOXFIELD RD STE 203
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City | ST CHARLES
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State | IL
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Zip | 60174-1406
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Country | US
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Telephone | 630-587-4444
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Fax | 630-587-5811
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Provider Business Mailing Address
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Address Line | 2570 FOXFIELD RD STE 203
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City | ST CHARLES
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State | IL
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Zip | 60174-1406
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Country | US
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Telephone | 630-587-4444
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Fax | 630-587-5811
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Authorized Official
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Title or Position | OWNER
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Name | DR. KYLE E PEDERSEN
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Credential | DDS
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Telephone | 630-587-4444
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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 | 021001694
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License Number State | IL
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