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General NPI Number Information
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NPI Number | 1861779373
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Entity Type | Organization
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Legal Business Name | JSAM, LLC
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Dates
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Enumeration Date | 11/11/2011
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Last Update Date | 11/14/2011
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Provider Practice Location Address
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Address Line | 420 E MAIN ST BUILDING 3, SUITE #17
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City | BRANFORD
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State | CT
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Zip | 06405-2940
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Country | US
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Telephone | 203-488-6553
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Fax |
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Provider Business Mailing Address
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Address Line | 420 E MAIN ST BUILDING 3, SUITE #17
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City | BRANFORD
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State | CT
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Zip | 06405-2940
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Country | US
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Telephone | 203-488-6553
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. JOHN MICHALAK
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Credential | DMD
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Telephone | 203-488-6553
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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 | 009451
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License Number State | CT
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