Provider Demographics
NPI:1528401635
Name:ROSS, TAYLOR RANDOLPH
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:RANDOLPH
Last Name:ROSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13006 E 17TH PLACE
Mailing Address - Street 2:UNIVERSITY OF COLORADO SCHOOL OF DENTAL MEDICINE
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80045-2581
Mailing Address - Country:US
Mailing Address - Phone:303-724-6496
Mailing Address - Fax:
Practice Address - Street 1:120 S STARDUST DR
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-1631
Practice Address - Country:US
Practice Address - Phone:719-547-4474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002021151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice