Healthcare Provider Details

I. General information

NPI: 1376606350
Provider Name (Legal Business Name): MICHAEL MARTIN TAYLOR DDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2007
Certification Date:
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: 505-622-4369
  • Fax: 505-622-8557
Mailing address:
  • Phone: 505-622-4369
  • Fax: 505-622-8557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1725
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: