Provider Demographics
NPI:1669671160
Name:TAYLOR, SHELLEY SEGREST (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:SEGREST
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:SHELLEY
Other - Middle Name:ANNE
Other - Last Name:SEGREST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:500 COURT ST
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:MS
Mailing Address - Zip Code:39367-2631
Mailing Address - Country:US
Mailing Address - Phone:601-735-5462
Mailing Address - Fax:601-735-0901
Practice Address - Street 1:500 COURT ST
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:MS
Practice Address - Zip Code:39367-2631
Practice Address - Country:US
Practice Address - Phone:601-735-5462
Practice Address - Fax:601-735-0901
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MS3414-07122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I195834Medicare PIN
302I195880Medicare PIN