Provider Demographics
NPI:1669619367
Name:JUANITA R. TAYLOR, DDS, LLC
Entity type:Organization
Organization Name:JUANITA R. TAYLOR, DDS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:RENAE
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-968-9700
Mailing Address - Street 1:4615 LAFAYETTE RD STE B
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-2035
Mailing Address - Country:US
Mailing Address - Phone:317-968-9700
Mailing Address - Fax:
Practice Address - Street 1:4615 LAFAYETTE RD STE B
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-2035
Practice Address - Country:US
Practice Address - Phone:317-968-9700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-16
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental