Provider Demographics
NPI:1588747737
Name:TAYLOR, JEFFERY Y (DMD)
Entity type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:Y
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 1:1122 DEMOURELLE RD
Mailing Address - Street 2:
Mailing Address - City:PASS CHRISTIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39571-4224
Mailing Address - Country:US
Mailing Address - Phone:228-452-0777
Mailing Address - Fax:
Practice Address - Street 1:431 SECURITY SQ
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-1922
Practice Address - Country:US
Practice Address - Phone:228-896-4325
Practice Address - Fax:228-896-5787
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS26491223P0300X
GAPER242931223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
696993OtherACTIVE DUTY MILITARY