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General NPI Number Information
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NPI Number | 1881610855
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Entity Type | Individual
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Provider Name | JUAN KEVIN PACKER D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/14/2006
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Last Update Date | 03/15/2021
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Provider Practice Location Address
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Address Line | 1321 NW SAINT LUCIE WEST BLVD
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City | PORT ST LUCIE
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State | FL
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Zip | 34986-2139
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Country | US
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Telephone | 772-343-0179
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Fax |
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Provider Business Mailing Address
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Address Line | 2188 SW 176TH TER
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City | MIRAMAR
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State | FL
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Zip | 33029-5258
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Country | US
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Telephone | 954-612-4509
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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 | 1223D0001X
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Taxonomy Name | Public Health Dentistry
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License Number | 3046-98
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License Number State | MS
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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 | DN18188
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License Number State | FL
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