Provider Demographics
NPI:1609250810
Name:SAN JUAN DENTAL ANESTHESIA SERVICES, PROFESSIONAL LLC
Entity Type:Organization
Organization Name:SAN JUAN DENTAL ANESTHESIA SERVICES, PROFESSIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-247-4848
Mailing Address - Street 1:835 E 2ND AVE
Mailing Address - Street 2:SUITE 270
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5475
Mailing Address - Country:US
Mailing Address - Phone:970-247-4848
Mailing Address - Fax:877-888-7642
Practice Address - Street 1:835 E 2ND AVE
Practice Address - Street 2:SUITE 270
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5475
Practice Address - Country:US
Practice Address - Phone:970-247-4848
Practice Address - Fax:877-888-7642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2018901223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Single Specialty