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Individual
JIA OOI
Active
Individual
JIA OOI
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DMD
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
9504
KY
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
9504
KY
Other
Enumeration date
03/17/2014
Last updated
03/22/2017
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