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General NPI Number Information
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NPI Number | 1851788988
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Entity Type | Individual
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Provider Name | RACHAEL ANNE WILSON
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Gender | Female
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Dates
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Enumeration Date | 04/15/2015
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Last Update Date | 08/16/2016
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Provider Practice Location Address
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Address Line | 4200 WEST OLD SHAKOPEE RD SUITE 100
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City | BLOOMINGTON
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State | MN
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Zip | 55437
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Country | US
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Telephone | 952-831-6126
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Fax |
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Provider Business Mailing Address
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Address Line | 3800 12TH AVE S
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City | MINNEAPOLIS
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State | MN
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Zip | 55407-2731
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Country | US
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Telephone | 406-672-0187
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | D13547
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License Number State | MN
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