MEDICARE: BLAKE YOUNG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	12743	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1275751224	OTHER	NC	LEAL, SPANGLER AND JOHNSON DDS, PA GROUP NPI

General Provider Information

NPI Number	:	1457005654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLAKE YOUNG

Provider Business Mailing Address
First Line	:	1000 SOUTHPARK BLVD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27127-5072
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 SOUTHPARK BLVD STE C
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27127-5072
Country	:	US
Telephone Number	:	336-788-5073
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2022
Last Update Date	:	08/02/2022

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Directions to “ BLAKE YOUNG ” Practice Location

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