Healthcare Provider Details

I. General information

NPI: 1235751652
Provider Name (Legal Business Name): TAYLOR RUSSEL SHORT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1059 BARTON DR
FORDLAND MO
65652-7350
US

IV. Provider business mailing address

1059 BARTON DR
FORDLAND MO
65652-7350
US

V. Phone/Fax

Practice location:
  • Phone: 417-767-2273
  • Fax: 417-767-2273
Mailing address:
  • Phone: 417-767-2273
  • Fax: 417-767-4054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number7336
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2020018039
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: