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General NPI Number Information
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NPI Number | 1871996199
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Entity Type | Organization
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Legal Business Name | SULLIVAN FAMILY DENTISTRY, LLC
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Dates
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Enumeration Date | 10/01/2014
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Last Update Date | 01/08/2020
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Provider Practice Location Address
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Address Line | 2186 N HOSPITAL BLVD., SUITE 1
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City | SULLIVAN
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State | IN
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Zip | 47882-0468
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Country | US
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Telephone | 812-268-4010
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Fax | 812-268-5607
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Provider Business Mailing Address
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Address Line | PO BOX 468
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City | SULLIVAN
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State | IN
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Zip | 47882-0468
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Country | US
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Telephone | 812-268-4010
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Fax | 812-268-5607
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Authorized Official
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Title or Position | SENIOR PARTNER OWNER
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Name | DR. GREGG W SMITH
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Credential | DDS
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Telephone | 812-268-4010
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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 | 12007736A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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