Provider Demographics
NPI:1114017662
Name:TAYLOR, BRENDA JEAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:JEAN
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11139 S HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-3910
Mailing Address - Country:US
Mailing Address - Phone:773-995-1234
Mailing Address - Fax:773-995-9796
Practice Address - Street 1:701 WEST 111TH STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628
Practice Address - Country:US
Practice Address - Phone:773-995-1234
Practice Address - Fax:773-995-9796
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-023707122300000X
IL0190237071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200248120Medicaid