Healthcare Provider Details

I. General information

NPI: 1316623762
Provider Name (Legal Business Name): ELIZA TAYLOR DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8935 GOODMAN RD
OLIVE BRANCH MS
38654-2201
US

IV. Provider business mailing address

109 HIDDEN HTS
GREENEVILLE TN
37743-6620
US

V. Phone/Fax

Practice location:
  • Phone: 628-955-0126
  • Fax:
Mailing address:
  • Phone: 423-914-0558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: