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General NPI Number Information
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NPI Number | 1871086405
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Entity Type | Individual
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Provider Name | MATEO VIDALES DMD
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Gender | Male
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Dates
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Enumeration Date | 06/08/2018
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Last Update Date | 06/08/2018
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Provider Practice Location Address
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Address Line | 7700 LAKE WILSON RD
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City | DAVENPORT
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State | FL
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Zip | 33896-9601
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Country | US
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Telephone | 863-420-3166
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Fax |
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Provider Business Mailing Address
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Address Line | 1640 WISE DR
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City | NORTH PORT
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State | FL
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Zip | 34286-6830
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Country | US
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Telephone | 941-408-6601
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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 | 23425
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License Number State | FL
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