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General NPI Number Information
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NPI Number | 1881290872
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Entity Type | Organization
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Legal Business Name | UNION GROVE FAMILY DENTAL, LLC
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Dates
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Enumeration Date | 12/07/2020
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Last Update Date | 12/07/2020
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Provider Practice Location Address
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Address Line | 1680 15TH AVE
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City | UNION GROVE
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State | WI
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Zip | 53182-1525
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Country | US
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Telephone | 262-878-1500
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Fax |
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Provider Business Mailing Address
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Address Line | 1680 15TH AVE
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City | UNION GROVE
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State | WI
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Zip | 53182-1525
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | KRISTIN M LENZ GALBREATH
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Credential | DMD
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Telephone | 262-930-8297
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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