Provider Demographics
NPI:1891271474
Name:TAYLOR, COLTER SETH
Entity Type:Individual
Prefix:
First Name:COLTER
Middle Name:SETH
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 ELK ST
Mailing Address - Street 2:
Mailing Address - City:GASSAWAY
Mailing Address - State:WV
Mailing Address - Zip Code:26624-1113
Mailing Address - Country:US
Mailing Address - Phone:304-364-8565
Mailing Address - Fax:
Practice Address - Street 1:715 ELK ST
Practice Address - Street 2:
Practice Address - City:GASSAWAY
Practice Address - State:WV
Practice Address - Zip Code:26624-1113
Practice Address - Country:US
Practice Address - Phone:304-364-8565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4343122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist