Provider Demographics
NPI:1184290694
Name:FALLON, TAYLOR
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:FALLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4200 E RIVER RD UNIT A
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-6933
Mailing Address - Country:US
Mailing Address - Phone:520-999-0772
Mailing Address - Fax:
Practice Address - Street 1:4200 E RIVER RD UNIT A
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-6933
Practice Address - Country:US
Practice Address - Phone:520-999-0772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZXBP850158312OtherBLUE CROSS BLUE SHIELD OF ARIZONA