Provider Demographics
NPI:1609811066
Name:TAUB, DANIEL IAN (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:IAN
Last Name:TAUB
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:909 WALNUT STREET
Mailing Address - Street 2:300COB
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5211
Mailing Address - Country:US
Mailing Address - Phone:215-955-6215
Mailing Address - Fax:215-923-9189
Practice Address - Street 1:909 WALNUT STREET
Practice Address - Street 2:300 COB
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5211
Practice Address - Country:US
Practice Address - Phone:215-955-6215
Practice Address - Fax:215-923-9189
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS030442L1223S0112X
PAMD430367204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011106450001Medicaid
PA1011106450001Medicaid
PA071445RA9Medicare ID - Type Unspecified
PA1011106450001Medicaid