Healthcare Provider Details

I. General information

NPI: 1144219452
Provider Name (Legal Business Name): DARRYL LYNN TAYLOR D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1ST DENTAL BATTALION, NAVAL DENTAL CENTER CAMP PENDLETON MARINE BASE
CAMP PENDLETON CA
92055-5221
US

IV. Provider business mailing address

1105 TEAL WAY
OCEANSIDE CA
92057-1837
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-5102
  • Fax: 760-725-5779
Mailing address:
  • Phone: 760-529-9822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11142
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: