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Individual
Inactive
Individual
Inactive
Sole proprietor
Provider details
NPI number
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
DE00004934
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
55240-04
—
WA
01
—
5524004
WA DENTAL SERVICE
WA
Enumeration date
—
Last updated
—
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