Basic Information
| Provider Information | |||||||||
| NPI: | 1235359738 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TAOS FAMILY DENTISTRY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1335 GUSDORF RD STE A | ||||||||
| Address2: | |||||||||
| City: | TAOS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875715206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057519333 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1335 GUSDORF RD STE A | ||||||||
| Address2: | |||||||||
| City: | TAOS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875715206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057519333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HOSHAW | ||||||||
| AuthorizedOfficialFirstName: | LANI | ||||||||
| AuthorizedOfficialMiddleName: | LEIGH | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN OF THE BOARD | ||||||||
| AuthorizedOfficialTelephone: | 5057519333 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DD1823 | NM | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 1223G0001X | DD2176 | NM | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 013118 | 05 | NM | MEDICAID | 13118 | 05 | NM | MEDICAID | 0015467 | 05 | NM | MEDICAID |