Healthcare Provider Details

I. General information

NPI: 1154414886
Provider Name (Legal Business Name): EDWARD D YOUNG DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4310 LEONARD NW
GRAND RAPIDS MI
49534
US

IV. Provider business mailing address

4310 LEONARD NW
GRAND RAPIDS MI
49534
US

V. Phone/Fax

Practice location:
  • Phone: 616-791-0230
  • Fax:
Mailing address:
  • Phone: 616-791-0230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901013995
License Number StateMI

VIII. Authorized Official

Name: DR. EDWARD D YOUNG
Title or Position: PRESIDENT
Credential: DDS
Phone: 616-791-0230