Healthcare Provider Details

I. General information

NPI: 1831672229
Provider Name (Legal Business Name): HEIDI LYNN TAYLOR RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E 14TH AVE
CORDELE GA
31015-1422
US

IV. Provider business mailing address

702 E 19TH AVE
CORDELE GA
31015-1748
US

V. Phone/Fax

Practice location:
  • Phone: 229-273-4330
  • Fax:
Mailing address:
  • Phone: 229-287-1583
  • Fax: 229-273-4347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH010466
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: