Provider Demographics
NPI:1386373074
Name:THORNTON, TAYLOR STEFAN
Entity type:Individual
Prefix:MR
First Name:TAYLOR
Middle Name:STEFAN
Last Name:THORNTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 RICHARD MARTIN DR UNIT 202
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82007-2049
Mailing Address - Country:US
Mailing Address - Phone:509-430-6947
Mailing Address - Fax:
Practice Address - Street 1:229 STOREY BLVD STE A
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-3595
Practice Address - Country:US
Practice Address - Phone:502-852-5096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-07
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY16451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice