Provider Demographics
NPI:1497897920
Name:TAYLOR, ANNIE W (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANNIE
Middle Name:W
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 W NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-4502
Mailing Address - Country:US
Mailing Address - Phone:601-981-1406
Mailing Address - Fax:601-981-1425
Practice Address - Street 1:505 W NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-4502
Practice Address - Country:US
Practice Address - Phone:601-981-1406
Practice Address - Fax:601-981-1425
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1815781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00064669Medicaid
MS00064669Medicaid