Provider Demographics
NPI:1821127549
Name:GLENN N TAYLOR JR DMD MD PA
Entity Type:Organization
Organization Name:GLENN N TAYLOR JR DMD MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:N
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD MD
Authorized Official - Phone:904-261-6068
Mailing Address - Street 1:4202 NW 155TH TERRACE
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32669
Mailing Address - Country:US
Mailing Address - Phone:352-332-2876
Mailing Address - Fax:352-332-1113
Practice Address - Street 1:1947 CITRONA DRIVE
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034
Practice Address - Country:US
Practice Address - Phone:904-261-6068
Practice Address - Fax:904-261-9797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN131871223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty