Provider Demographics
NPI:1093273070
Name:TAYLOR, MATTHEW B
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:B
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 DERBY ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-1836
Mailing Address - Country:US
Mailing Address - Phone:718-839-0092
Mailing Address - Fax:
Practice Address - Street 1:213 HALLOCK RD STE 4A
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3000
Practice Address - Country:US
Practice Address - Phone:631-762-9910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-07
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0619191223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty