Healthcare Provider Details

I. General information

NPI: 1609250810
Provider Name (Legal Business Name): SAN JUAN DENTAL ANESTHESIA SERVICES, PROFESSIONAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 07/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 E 2ND AVE SUITE 270
DURANGO CO
81301-5475
US

IV. Provider business mailing address

835 E 2ND AVE SUITE 270
DURANGO CO
81301-5475
US

V. Phone/Fax

Practice location:
  • Phone: 970-247-4848
  • Fax: 877-888-7642
Mailing address:
  • Phone: 970-247-4848
  • Fax: 877-888-7642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number201890
License Number StateCO

VIII. Authorized Official

Name: DR. TAYLOR CLARK
Title or Position: OWNER
Credential: D.D.S.
Phone: 970-247-4848