Provider Demographics
NPI:1275223414
Name:BRUBAKER, TAYLOR
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:BRUBAKER
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 1:17-148 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:LANARK
Mailing Address - State:IL
Mailing Address - Zip Code:61046-9366
Mailing Address - Country:US
Mailing Address - Phone:815-494-2351
Mailing Address - Fax:
Practice Address - Street 1:1717 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4695
Practice Address - Country:US
Practice Address - Phone:815-233-9777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-10
Last Update Date:2025-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190363641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice