=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043990963
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB TAYLOR DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2023
-----------------------------------------------------
Last Update Date | 05/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1647 ADMIRAL TAUSSIG BLVD
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23511-2803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-953-8608
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1203 SHERWOOD CT
-----------------------------------------------------
City | BELLEFONTE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16823-2554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-574-5223
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DEN.00205686
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------