Provider Demographics
NPI:1932692530
Name:TAYLOR, JORDAN ALLEN (DMD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ALLEN
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2772 ANNELISE LN
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-4529
Mailing Address - Country:US
Mailing Address - Phone:801-512-7421
Mailing Address - Fax:
Practice Address - Street 1:5227 S MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4916
Practice Address - Country:US
Practice Address - Phone:801-512-7421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX341221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice