Provider Demographics
NPI:1467403253
Name:TAYLOR, KELLY ELDON (DMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELDON
Last Name:TAYLOR
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 1:52 DONRITA CT
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-8018
Mailing Address - Country:US
Mailing Address - Phone:509-593-4739
Mailing Address - Fax:
Practice Address - Street 1:860 S 2ND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4072
Practice Address - Country:US
Practice Address - Phone:509-529-2000
Practice Address - Fax:509-529-4590
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000086801223P0700X
ORD87321223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR171037Medicaid