Healthcare Provider Details

I. General information

NPI: 1730363730
Provider Name (Legal Business Name): JOHN BENNETT TAYLOR D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

691 LANIER PARK DR
GAINESVILLE GA
30501-2060
US

IV. Provider business mailing address

691 LANIER PARK DRIVE
GAINESVILLE GA
30501
US

V. Phone/Fax

Practice location:
  • Phone: 770-287-0044
  • Fax: 770-287-8091
Mailing address:
  • Phone: 770-287-0044
  • Fax: 770-287-8091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number010181
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: