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General NPI Number Information
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NPI Number | 1912571027
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Entity Type | Organization
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Legal Business Name | BLAKE K ANDERSON DMD LLC
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Dates
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Enumeration Date | 05/14/2021
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Last Update Date | 05/14/2021
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Provider Practice Location Address
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Address Line | 828 NE A ST
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City | GRANTS PASS
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State | OR
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Zip | 97526-2212
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Country | US
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Telephone | 541-476-9792
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Fax |
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Provider Business Mailing Address
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Address Line | 4674 E FOXWOOD DR
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City | EAGLE MOUNTAIN
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State | UT
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Zip | 84005-6176
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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 | DOCTOR/OWNER
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Name | DR. BLAKE K ANDERSON
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Credential | DMD
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Telephone | 916-765-7036
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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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