Provider Demographics
NPI:1306937008
Name:BOU, TAYLOR TAEKIU (DDS)
Entity type:Individual
Prefix:DR
First Name:TAYLOR
Middle Name:TAEKIU
Last Name:BOU
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1995 ROUTE 17M
Mailing Address - Street 2:FLOOR 1
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-5231
Mailing Address - Country:US
Mailing Address - Phone:845-651-6038
Mailing Address - Fax:
Practice Address - Street 1:1995 ROUTE 17M
Practice Address - Street 2:FLOOR 1
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-5231
Practice Address - Country:US
Practice Address - Phone:845-651-6038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049304-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice