Healthcare Provider Details

I. General information

NPI: 1386683530
Provider Name (Legal Business Name): AMY KAY DEYOUNG DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3297 EAGLE RUN DR NE
GRAND RAPIDS MI
49525-7050
US

IV. Provider business mailing address

3297 EAGLE RUN DR NE
GRAND RAPIDS MI
49525-7050
US

V. Phone/Fax

Practice location:
  • Phone: 616-447-7900
  • Fax: 616-447-7902
Mailing address:
  • Phone: 616-447-7900
  • Fax: 616-447-7902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2901016365
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: