Healthcare Provider Details

I. General information

NPI: 1760407134
Provider Name (Legal Business Name): KIRK TAYLOR DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 CENTERVILLE HWY SUITE F
SNELLVILLE GA
30039-8005
US

IV. Provider business mailing address

3400 CENTERVILLE HWY SUITE F
SNELLVILLE GA
30039-8005
US

V. Phone/Fax

Practice location:
  • Phone: 770-985-2325
  • Fax: 770-985-6946
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10248
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: