Healthcare Provider Details

I. General information

NPI: 1740574060
Provider Name (Legal Business Name): TAYLOR DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2011
Last Update Date: 06/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 S 2ND AVE STE A
WALLA WALLA WA
99362-4072
US

IV. Provider business mailing address

860 S 2ND AVE STE A
WALLA WALLA WA
99362-4072
US

V. Phone/Fax

Practice location:
  • Phone: 509-529-2000
  • Fax: 509-529-4590
Mailing address:
  • Phone: 509-529-2000
  • Fax: 509-529-4590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDE 00008680
License Number StateWA

VIII. Authorized Official

Name: DR. KELLY E TAYLOR
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 509-529-2000