Basic Information
| Provider Information | |||||||||
| NPI: | 1609811066 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAUB | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | IAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS, MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 909 WALNUT STREET | ||||||||
| Address2: | 300COB | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159556215 | ||||||||
| FaxNumber: | 2159239189 | ||||||||
| Practice Location | |||||||||
| Address1: | 909 WALNUT STREET | ||||||||
| Address2: | 300 COB | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159556215 | ||||||||
| FaxNumber: | 2159239189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | DS030442L | PA | N | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 204E00000X | MD430367 | PA | Y | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1011106450001 | 05 | PA | MEDICAID |