Healthcare Provider Details

I. General information

NPI: 1053956466
Provider Name (Legal Business Name): TASKER HATCH ROWAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2019
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 CABEZON BLVD SE STE 104
RIO RANCHO NM
87124-1513
US

IV. Provider business mailing address

325 S HIGLEY RD #130
GILBERT AZ
85296
US

V. Phone/Fax

Practice location:
  • Phone: 505-891-5145
  • Fax:
Mailing address:
  • Phone: 505-850-3769
  • Fax: 505-890-2949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

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