Provider Demographics
NPI:1821579988
Name:TAYLOR, KELLY (RDH)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
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 1:10 LUCILE ST UNIT E
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-4491
Mailing Address - Country:US
Mailing Address - Phone:850-376-4262
Mailing Address - Fax:
Practice Address - Street 1:82 LYNN DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-4200
Practice Address - Country:US
Practice Address - Phone:850-974-0780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH11693124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist