Healthcare Provider Details

I. General information

NPI: 1467484097
Provider Name (Legal Business Name): KERA YOUNG DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 03/07/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13131 KINGS LAKE DRIVE SUITE 104
GIBSONTON FL
33534
US

IV. Provider business mailing address

PO BOX 486
LITHIA FL
33547-0486
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN15193
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: