Provider Demographics
NPI:1124117718
Name:TAYLOR, JENNIFER LYNN (DDS)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7524 S ANTHONY BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46816-2523
Mailing Address - Country:US
Mailing Address - Phone:260-441-8500
Mailing Address - Fax:
Practice Address - Street 1:7524 S ANTHONY BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46816-2517
Practice Address - Country:US
Practice Address - Phone:260-441-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010849A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201238440AMedicaid