Provider Demographics
NPI:1306411731
Name:DAVIS, TAYLOR DAMIAN
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:DAMIAN
Last Name:DAVIS
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 1:10411 GRAND VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-4261
Mailing Address - Country:US
Mailing Address - Phone:702-843-9111
Mailing Address - Fax:
Practice Address - Street 1:971 COUNTY ROAD E E
Practice Address - Street 2:
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55127-7114
Practice Address - Country:US
Practice Address - Phone:651-877-1009
Practice Address - Fax:651-666-2974
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3724152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist