Healthcare Provider Details

I. General information

NPI: 1083084347
Provider Name (Legal Business Name): VIRGINIA YOUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 10/24/2020
Certification Date: 10/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2169 GLEBE ST STE 200
CARMEL IN
46032-7380
US

IV. Provider business mailing address

1035 W JEFFERSON ST
FRANKLIN IN
46131-2123
US

V. Phone/Fax

Practice location:
  • Phone: 317-575-6101
  • Fax:
Mailing address:
  • Phone: 317-736-6361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12012290B
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12012290A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: