MEDICARE: DR. TAYLOR HOUSTON SHANK DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	6868	LA

General Provider Information

NPI Number	:	1942791538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TAYLOR HOUSTON SHANK DDS

Provider Business Mailing Address
First Line	:	206 HEATHEROAK AVE
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70506-5834
Country	:	US
Telephone Number	:	337-852-2803
Fax Number	:

Provider Business Practice Location Address
First Line	:	4243 AMBASSADOR CAFFERY PKWY STE 118
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-7268
Country	:	US
Telephone Number	:	337-422-3587
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2018
Last Update Date	:	05/20/2018

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