Healthcare Provider Details

I. General information

NPI: 1114532181
Provider Name (Legal Business Name): TAYLOR ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W WILSHIRE BLVD STE E
ROSWELL NM
88201-0627
US

IV. Provider business mailing address

200 W WILSHIRE BLVD STE E
ROSWELL NM
88201-0627
US

V. Phone/Fax

Practice location:
  • Phone: 575-622-4369
  • Fax:
Mailing address:
  • Phone: 575-622-4369
  • Fax:

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: FAITH GASKINS
Title or Position: DIRECTOR OF CREDENTIALING
Credential:
Phone: 972-869-3789