Provider Demographics
NPI:1235751652
Name:SHORT, TAYLOR RUSSEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:TAYLOR
Middle Name:RUSSEL
Last Name:SHORT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1059 BARTON DR
Mailing Address - Street 2:
Mailing Address - City:FORDLAND
Mailing Address - State:MO
Mailing Address - Zip Code:65652-7350
Mailing Address - Country:US
Mailing Address - Phone:417-767-2273
Mailing Address - Fax:417-767-4054
Practice Address - Street 1:1059 BARTON DR
Practice Address - Street 2:
Practice Address - City:FORDLAND
Practice Address - State:MO
Practice Address - Zip Code:65652-7350
Practice Address - Country:US
Practice Address - Phone:417-767-2273
Practice Address - Fax:417-767-2273
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-07
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7336122300000X
MO2020018039122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist