Provider Demographics
NPI:1538212287
Name:TAVERAS, JUAN CARLOS (DDS)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:TAVERAS
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 1:950 YALE AVE STE 31
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-1884
Mailing Address - Country:US
Mailing Address - Phone:203-793-7084
Mailing Address - Fax:203-626-9542
Practice Address - Street 1:950 YALE AVE STE 31
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-1884
Practice Address - Country:US
Practice Address - Phone:203-793-7084
Practice Address - Fax:203-626-9542
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043019122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01263565Medicaid