Taylor Russel Short, DDS
Individual provider Active NPI Dentist · Fordland, MO
NPI 1235751652 · NPPES record last updated Aug 10, 2021
Key facts
- NPI
- 1235751652
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 2020018039 (MO)
- Practice address
- 1059 Barton Dr
Fordland, MO 65652-7350 - Phone
- (417) 767-2273
- Fax
- (417) 767-2273
- NPI assigned
- May 7, 2020
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 3
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MO
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20200630002498 | MO | Practitioner - Dentist | 3870916372 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2020018039 | MO | MD | Dentist |
| 7336 | OK | MD | Diagnostic Radiology Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Advocates for a Healthy Community Inc | Current |
Accepting new patients | |
| Advocates for a Healthy Community, Inc | Current |
Accepting new patients | |
| Fordland Clinic, Inc. | Past | Accepting new patients |
Locations
33 Gage Dr
#5862
Hollister, MO 65672
Phone (417) 334-8300
440 E Tampa St
Springfield, MO 65806
Phone (417) 831-0191
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 7336 | OK | |
| Dentist | 122300000X | 2020018039 | MO | Yes |
Addresses
Primary practice location
1059 Barton Dr
Fordland, MO 65652-7350
Mailing address
1059 Barton Dr
Fordland, MO 65652-7350
Phone (417) 767-2273
Other providers in Fordland, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 10, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.