Healthcare Provider Details

I. General information

NPI: 1225468242
Provider Name (Legal Business Name): YOUNG SMILES PEDIATRIC DENTISTRY & SPA P.A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2013
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13131 KINGS LAKE DR SUITE # 104
GIBSONTON FL
33534-3959
US

IV. Provider business mailing address

PO BOX 486
LITHIA FL
33547-0486
US

V. Phone/Fax

Practice location:
  • Phone: 813-829-9075
  • Fax: 813-236-9006
Mailing address:
  • Phone: 813-829-9075
  • Fax: 813-236-9007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. KERA YOUNG
Title or Position: PEDODONTIST
Credential: DDS
Phone: 813-829-9075