Provider Demographics
NPI:1588876338
Name:TAYLOR, CHARLES GLENN (DDS, MS)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:GLENN
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2356 GROVE STREET
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183
Mailing Address - Country:US
Mailing Address - Phone:601-638-8230
Mailing Address - Fax:
Practice Address - Street 1:2356 GROVE STREET
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183
Practice Address - Country:US
Practice Address - Phone:601-638-8230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1770-771223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSOR-015-COtherORTHODONTIC SPECIALTY
MS1770-77OtherDENTAL LICENSE
MS00660431Medicaid