Healthcare Provider Details

I. General information

NPI: 1023097482
Provider Name (Legal Business Name): DWIGHT LAUGHTON YOUNGMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3305 MILLER ST
BETHANY MO
64424-2716
US

IV. Provider business mailing address

PO BOX 128 3305 MILLER STREET
BETHANY MO
64424-0128
US

V. Phone/Fax

Practice location:
  • Phone: 660-425-3616
  • Fax:
Mailing address:
  • Phone: 660-425-3616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD012121
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: