Healthcare Provider Details

I. General information

NPI: 1033381603
Provider Name (Legal Business Name): TASKER HATCH ROWAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2008
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 EAGLE RANCH RD NW
ALBUQUERQUE NM
87114-6032
US

IV. Provider business mailing address

325 S HIGLEY #130
GILBERT AZ
85296
US

V. Phone/Fax

Practice location:
  • Phone: 505-892-9010
  • Fax: 505-899-4804
Mailing address:
  • Phone: 505-850-3769
  • Fax: 505-890-2949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDD2829
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2829
License Number StateNM

VIII. Authorized Official

Name: EBONIE GONZALES
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 505-850-3769