Provider Demographics
NPI:1720181852
Name:EAST TAYLOR DENTAL PC
Entity Type:Organization
Organization Name:EAST TAYLOR DENTAL PC
Other - Org Name:EASTDALE DENTAL GROUP PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KILLIAN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:HORNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:334-271-4600
Mailing Address - Street 1:2201 TAYLOR ROAD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-3498
Mailing Address - Country:US
Mailing Address - Phone:334-271-4600
Mailing Address - Fax:334-271-4709
Practice Address - Street 1:2201 TAYLOR ROAD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3498
Practice Address - Country:US
Practice Address - Phone:334-271-4600
Practice Address - Fax:334-271-4709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
816933OtherUNITED CONCORDIA
AL90188OtherBCBS