Provider Demographics
NPI:1124599105
Name:FDC OF LAUREL LLC
Entity Type:Organization
Organization Name:FDC OF LAUREL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:S
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-428-0082
Mailing Address - Street 1:PO BOX 6505
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-6505
Mailing Address - Country:US
Mailing Address - Phone:601-428-0082
Mailing Address - Fax:
Practice Address - Street 1:1532 W 15TH ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-2102
Practice Address - Country:US
Practice Address - Phone:601-428-0082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty