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General NPI Number Information
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NPI Number | 1891594016
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Entity Type | Organization
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Legal Business Name | MIRROR IMAGE DENTAL LLC
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Dates
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Enumeration Date | 03/11/2025
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Last Update Date | 03/11/2025
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Provider Practice Location Address
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Address Line | 4710 E CACTUS RD
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City | PHOENIX
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State | AZ
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Zip | 85032-7706
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Country | US
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Telephone | 480-442-0225
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Fax |
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Provider Business Mailing Address
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Address Line | 1601 E POTTER DR
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City | PHOENIX
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State | AZ
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Zip | 85024-4334
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Country | US
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Telephone | 602-705-9168
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Fax |
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Authorized Official
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Title or Position | CEO / OWNER DENTIST
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Name | DR. SHAWN MICHAEL MAULE
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Credential | DDS
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Telephone | 602-705-9168
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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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