1417012774 NPI number — MARVIN S. TAYLOR DDS PC

Table of content: (NPI 1417012774)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417012774 NPI number — MARVIN S. TAYLOR DDS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARVIN S. TAYLOR DDS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DR TAYLORS FAMILY DENTAL CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417012774
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1770 GOLF RIDGE DR S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMFIELD HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48302-1730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-681-8100
Provider Business Mailing Address Fax Number:
248-681-6318

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 W HURON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERFORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48328-3736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-681-8100
Provider Business Practice Location Address Fax Number:
248-681-6318
Provider Enumeration Date:
12/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BAKER
Authorized Official First Name:
PATTY
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
248-681-8100

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  09568 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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