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General NPI Number Information
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NPI Number | 1972039501
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Entity Type | Organization
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Legal Business Name | MYSTLDENTIST LLC
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Dates
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Enumeration Date | 05/02/2017
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Last Update Date | 05/02/2017
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Provider Practice Location Address
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Address Line | 4590 S LINDBERGH BLVD
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City | SAINT LOUIS
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State | MO
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Zip | 63127-1832
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Country | US
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Telephone | 314-842-0440
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Fax | 314-849-5847
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Provider Business Mailing Address
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Address Line | 4590 S LINDBERGH BLVD
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City | SAINT LOUIS
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State | MO
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Zip | 63127-1832
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Country | US
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Telephone | 314-842-0440
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Fax | 314-848-5847
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Authorized Official
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Title or Position | SOLE MEMEBER
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Name | DR. WILLIAM EDWARD UTHOFF
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Credential | DMD
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Telephone | 314-842-0440
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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 | 013578
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License Number State | MO
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