MEDICARE: FAMILIA DENTAL CARLSBAD LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center
2	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1811333800
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILIA DENTAL CARLSBAD LLC

Provider Business Mailing Address
First Line	:	2050 EAST ALGONQUIN RD
Second Line	:	SUITE 610
City	:	SCHAUMBURG
State	:	IL
Zip	:	60173-4144
Country	:	US
Telephone Number	:	888-988-4066
Fax Number	:

Provider Business Practice Location Address
First Line	:	2330 W PIERCE ST
Second Line	:
City	:	CARLSBAD
State	:	NM
Zip	:	88220-3514
Country	:	US
Telephone Number	:	575-234-1125
Fax Number	:	575-234-1126

Authorized Official
Title or Position	:	CREDENTIALING PAYER RELATIONS MGR
Name	:	MR. BRANDON ALEXANDER TAYLOR
Credential	:	CPCS
Telephone Number	:	847-453-7396

Provider Enumeration Date	:	05/16/2013
Last Update Date	:	06/25/2021

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Directions to “FAMILIA DENTAL CARLSBAD LLC ” Practice Location

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