Provider Demographics
NPI:1881103026
Name:TAOS COUNTY DENTAL LLC
Entity type:Organization
Organization Name:TAOS COUNTY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL HUMAN RESOURCE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-344-5693
Mailing Address - Street 1:105 PASEO DEL CANON W STE B
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6943
Mailing Address - Country:US
Mailing Address - Phone:575-758-3205
Mailing Address - Fax:575-758-3756
Practice Address - Street 1:105 PASEO DEL CANON W STE B
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6943
Practice Address - Country:US
Practice Address - Phone:575-758-3205
Practice Address - Fax:575-758-3756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
CO202298261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO3889262Medicaid