Provider Demographics
NPI:1508224155
Name:TAYLOR, SHELLY (DMD)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-3416
Mailing Address - Country:US
Mailing Address - Phone:617-825-9839
Mailing Address - Fax:
Practice Address - Street 1:1894 WALTON AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-6018
Practice Address - Country:US
Practice Address - Phone:718-583-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-10
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 222911223G0001X
MADN1858222122300000X
390200000X
NY062433-011223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program