=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790272904
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAYLOR N SNIDER DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2018
-----------------------------------------------------
Last Update Date | 03/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1150 N LAKE SHORE DR APT 20G
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-5233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-738-6288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 91 FERNCROFT RD
-----------------------------------------------------
City | MILTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02186-2635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-867-0860
-----------------------------------------------------
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 | APPLYING
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------