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General NPI Number Information
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NPI Number | 1770158339
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Entity Type | Organization
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Legal Business Name | GOOD SHEPHERD MEDICAL/DENTAL CLINIC
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Dates
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Enumeration Date | 05/25/2021
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Last Update Date | 05/25/2021
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Provider Practice Location Address
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Address Line | 207 S 11TH AVE
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City | LAUREL
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State | MS
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Zip | 39440-4314
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Country | US
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Telephone | 601-426-2001
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Fax | 601-426-2002
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Provider Business Mailing Address
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Address Line | PO BOX 2704
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City | LAUREL
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State | MS
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Zip | 39442-2704
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Country | US
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Telephone | 601-426-2001
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Fax | 601-426-2002
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MR. DAVID WOLGAMOTT
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Credential |
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Telephone | 601-426-2001
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number |
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License Number State |
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