Provider Demographics
NPI:1508224155
Name:TAYLOR, SHELLY (DMD)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
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 1:636 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-3416
Mailing Address - Country:US
Mailing Address - Phone:617-825-9839
Mailing Address - Fax:
Practice Address - Street 1:636 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125-3416
Practice Address - Country:US
Practice Address - Phone:617-825-9839
Practice Address - Fax:617-825-6654
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-10
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN1858222122300000X
FLDN 222911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223G0001XDental ProvidersDentistGeneral Practice