Basic Information
Provider Information
NPI: 1003291162
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TAYLOR
FirstName: HEATHER
MiddleName: DANIELLE
NamePrefix: DR.
NameSuffix:  
Credential: DMD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1170 BELT LINE RD
Address2:  
City: COLLINSVILLE
State: IL
PostalCode: 622344372
CountryCode: US
TelephoneNumber: 6183451400
FaxNumber: 6183441401
Practice Location
Address1: 1170 BELT LINE RD
Address2:  
City: COLLINSVILLE
State: IL
PostalCode: 622344372
CountryCode: US
TelephoneNumber: 6183451400
FaxNumber: 6183441401
Other Information
ProviderEnumerationDate: 07/29/2015
LastUpdateDate: 09/23/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 09/23/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X019030243ILY Dental ProvidersDentist 

No ID Information.


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