Provider Demographics
NPI:1043732167
Name:TAYLOR, JONATHAN ROBERT
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ROBERT
Last Name:TAYLOR
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 1:615 GREEN ST NW STE 101
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3378
Mailing Address - Country:US
Mailing Address - Phone:770-532-2336
Mailing Address - Fax:770-532-3905
Practice Address - Street 1:615 GREEN ST NW STE 101
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3378
Practice Address - Country:US
Practice Address - Phone:770-532-2336
Practice Address - Fax:770-532-3905
Is Sole Proprietor?:No
Enumeration Date:2017-07-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015476122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist