Healthcare Provider Details

I. General information

NPI: 1790815249
Provider Name (Legal Business Name): WETUMPKA FAMILY DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4045 HWY 231
WETUMPKA AL
36093
US

IV. Provider business mailing address

4045 HWY 231
WETUMPKA AL
36093
US

V. Phone/Fax

Practice location:
  • Phone: 334-567-4334
  • Fax: 334-567-4248
Mailing address:
  • Phone: 334-567-4334
  • Fax: 334-567-4248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number4753
License Number StateAL

VIII. Authorized Official

Name: DR. DAVID C YOUNG
Title or Position: DENTIST
Credential: DMD
Phone: 334-567-4334