Provider Demographics
NPI:1760856272
Name:TAYLOR, AUDREY DIANE (RDH)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:DIANE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1393 COMPTON CT
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-2386
Mailing Address - Country:US
Mailing Address - Phone:517-272-5053
Mailing Address - Fax:
Practice Address - Street 1:5135 S PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4002
Practice Address - Country:US
Practice Address - Phone:517-272-5053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-20
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902016568124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist