Provider Demographics
NPI:1407415656
Name:BLAYLOCK, TAYLOR D (DMD)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:D
Last Name:BLAYLOCK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-2762
Mailing Address - Country:US
Mailing Address - Phone:662-710-4244
Mailing Address - Fax:
Practice Address - Street 1:1605 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-4127
Practice Address - Country:US
Practice Address - Phone:662-281-8455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4067122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist