Healthcare Provider Details

I. General information

NPI: 1306937008
Provider Name (Legal Business Name): TAYLOR TAEKIU BOU DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1995 ROUTE 17M FLOOR 1
GOSHEN NY
10924-5231
US

IV. Provider business mailing address

1995 ROUTE 17M FLOOR 1
GOSHEN NY
10924-5231
US

V. Phone/Fax

Practice location:
  • Phone: 845-651-6038
  • Fax:
Mailing address:
  • Phone: 845-651-6038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number049304-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: