Basic Information
| Provider Information | |||||||||
| NPI: | 1023688124 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LADD | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | AUSTIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 FORT FILLMORE RD | ||||||||
| Address2: | |||||||||
| City: | MESILLA PARK | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880479709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753126373 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 127 EL PASO RD | ||||||||
| Address2: | |||||||||
| City: | RUIDOSO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 883456033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5752579053 | ||||||||
| FaxNumber: | 5752581194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2021 | ||||||||
| LastUpdateDate: | 06/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DD5464 | NM | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | DD5464 | 01 | NM | NM DENTAL LICENSE NUMBER | OTHER |