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General NPI Number Information
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NPI Number | 1306178132
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Entity Type | Individual
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Provider Name | JUSTIN JACK NYLUND D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 02/04/2010
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Last Update Date | 12/13/2015
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Provider Practice Location Address
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Address Line | 1392 WEIMER RD STE A
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City | TAOS
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State | NM
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Zip | 87571-5308
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Country | US
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Telephone | 575-758-8654
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Fax | 575-737-0970
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Provider Business Mailing Address
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Address Line | 1392 WEIMER RD. SUITE A
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City | TAOS
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State | NM
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Zip | 87571
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Country | US
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Telephone | 575-758-8654
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Fax | 575-737-0970
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 10112
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DD3407
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License Number State | NM
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