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General NPI Number Information
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NPI Number | 1124599105
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Entity Type | Organization
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Legal Business Name | FDC OF LAUREL LLC
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Dates
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Enumeration Date | 12/17/2018
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Last Update Date | 12/17/2018
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Provider Practice Location Address
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Address Line | 1532 W 15TH ST
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City | LAUREL
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State | MS
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Zip | 39440-2102
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Country | US
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Telephone | 601-428-0082
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 6505
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City | LAUREL
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State | MS
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Zip | 39441-6505
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Country | US
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Telephone | 601-428-0082
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Fax |
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. SHELLEY S. TAYLOR
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Credential | DMD
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Telephone | 601-428-0082
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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