Basic Information
| Provider Information | |||||||||
| NPI: | 1750467957 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TAYLOR | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 42D MEDICAL GROUP | ||||||||
| Address2: | 300 S TWINNING ST. BLDG. 760 | ||||||||
| City: | MAXWELL AFB | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3349533368 | ||||||||
| FaxNumber: | 3349538607 | ||||||||
| Practice Location | |||||||||
| Address1: | 42D MEDICAL GROUP | ||||||||
| Address2: | 300 S. TWINNING ST. BLDG 760 | ||||||||
| City: | MAXWELL AFB | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134603877 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 01/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 30021784 | OH | N | Dental Providers | Dentist | 122300000X | DD4884 | NM | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 2417763 | 05 | OH | MEDICAID |