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General NPI Number Information
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NPI Number | 1942224332
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Entity Type | Individual
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Provider Name | KELLEY STEWART WILSON DMD
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Gender | Female
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Dates
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Enumeration Date | 07/27/2006
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Last Update Date | 09/07/2011
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Provider Practice Location Address
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Address Line | 5025 SE 28TH AVE
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City | PORTLAND
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State | OR
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Zip | 97202-4445
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Country | US
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Telephone | 503-238-4418
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Fax | 503-238-0360
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Provider Business Mailing Address
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Address Line | 19075 NW TANASBOURNE DR. #300 SUNSET DENTAL OFFICE
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City | HILLBORO
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State | OR
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Zip | 97124
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Country | US
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Telephone | 503-531-1700
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Fax | 503-531-1704
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | D7960
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License Number State | OR
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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 | D7960
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License Number State | OR
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