Healthcare Provider Details

I. General information

NPI: 1114659489
Provider Name (Legal Business Name): TAYLOR CLIFFE ROBERTSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2022
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22755 SUMMIT DR
WATERTOWN NY
13601-7233
US

IV. Provider business mailing address

111 E 210TH ST
BRONX NY
10467-2401
US

V. Phone/Fax

Practice location:
  • Phone: 315-405-4005
  • Fax:
Mailing address:
  • Phone: 718-920-5731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number065688
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: