Healthcare Provider Details

I. General information

NPI: 1962934612
Provider Name (Legal Business Name): TAYLOR L USITALO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 07/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2027 CERRILLOS RD
SANTA FE NM
87505-3269
US

IV. Provider business mailing address

2221 EAST BIJOU ST SUITE 100
COLORADO SPRINGS CO
80909-8009
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-1212
  • Fax: 505-820-1218
Mailing address:
  • Phone: 719-576-1850
  • Fax: 719-955-3470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD0000
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD0000
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD4663
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: