Provider Demographics
NPI:1386753044
Name:TAYLOR, JACK ROGERS (DMD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:ROGERS
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 1:843 HWY 277
Mailing Address - Street 2:
Mailing Address - City:CHIPLEY
Mailing Address - State:FL
Mailing Address - Zip Code:32428
Mailing Address - Country:US
Mailing Address - Phone:850-638-3055
Mailing Address - Fax:850-638-3056
Practice Address - Street 1:843 HWY 277
Practice Address - Street 2:
Practice Address - City:CHIPLEY
Practice Address - State:FL
Practice Address - Zip Code:32428
Practice Address - Country:US
Practice Address - Phone:850-638-3055
Practice Address - Fax:850-638-3056
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN12801122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist