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General NPI Number Information
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NPI Number | 1982100475
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Entity Type | Individual
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Provider Name | MICHELLE EMILY MODAD
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Gender | Female
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Dates
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Enumeration Date | 04/03/2018
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Last Update Date | 07/15/2024
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Provider Practice Location Address
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Address Line | 3023 80TH AVE SE STE 200
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City | MERCER ISLAND
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State | WA
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Zip | 98040-6014
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Country | US
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Telephone | 206-690-5417
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Fax |
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Provider Business Mailing Address
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Address Line | 2519 13TH AVE S
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City | SEATTLE
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State | WA
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Zip | 98144-5008
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Country | US
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Telephone | 573-308-0333
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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 | 1223D0004X
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Taxonomy Name | Dental Anesthesiology
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License Number | DE61149859
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License Number State | WA
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