Provider Demographics
NPI:1144717364
Name:MARTIN, TAYLOR BROOKE (RDA)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:BROOKE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15526 MAC ARTHUR DR
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72118-1593
Mailing Address - Country:US
Mailing Address - Phone:501-804-8286
Mailing Address - Fax:
Practice Address - Street 1:15526 MAC ARTHUR DR
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72118-1593
Practice Address - Country:US
Practice Address - Phone:501-804-8286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR12885126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant