Basic Information
| Provider Information | |||||||||
| NPI: | 1407216922 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAGGART | ||||||||
| FirstName: | COLIN | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | |||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 849 PACIFIC AVE | ||||||||
| Address2: | |||||||||
| City: | HOOD RIVER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970311956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413866380 | ||||||||
| FaxNumber: | 5413088370 | ||||||||
| Practice Location | |||||||||
| Address1: | 849 PACIFIC AVE | ||||||||
| Address2: | |||||||||
| City: | HOOD RIVER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970311956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413866380 | ||||||||
| FaxNumber: | 5413088370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2016 | ||||||||
| LastUpdateDate: | 03/15/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D10601 | OR | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 500725360 | 05 | OR | MEDICAID |