Provider Demographics
NPI:1316101025
Name:TAYLOR, TRACY NEAL (DMD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:NEAL
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 EAST LOCUST STREET
Mailing Address - Street 2:
Mailing Address - City:FAIRBURY
Mailing Address - State:IL
Mailing Address - Zip Code:61739
Mailing Address - Country:US
Mailing Address - Phone:815-692-4247
Mailing Address - Fax:
Practice Address - Street 1:202 EAST LOCUST STREET
Practice Address - Street 2:
Practice Address - City:FAIRBURY
Practice Address - State:IL
Practice Address - Zip Code:61739
Practice Address - Country:US
Practice Address - Phone:815-692-4247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL371296120122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist