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General NPI Number Information
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NPI Number | 1952089609
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Entity Type | Individual
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Provider Name | DR. CORDARYL LEE WHITEHEAD
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Gender | Male
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Dates
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Enumeration Date | 07/11/2023
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Last Update Date | 07/17/2023
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Provider Practice Location Address
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Address Line | 12517 YELLOW BLUFF RD
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City | JACKSONVILLE
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State | FL
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Zip | 32226-3809
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Country | US
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Telephone | 904-204-7496
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Fax |
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Provider Business Mailing Address
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Address Line | 9743 WATERSHED DR S
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City | JACKSONVILLE
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State | FL
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Zip | 32220-0903
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Country | US
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Telephone | 205-496-2310
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN28351
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License Number State | FL
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