Healthcare Provider Details

I. General information

NPI: 1811420888
Provider Name (Legal Business Name): MICHELLE YOUNG RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2017
Last Update Date: 04/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1059 BARTON DR
FORDLAND MO
65652-7350
US

IV. Provider business mailing address

1059 BARTON DR
FORDLAND MO
65652-7350
US

V. Phone/Fax

Practice location:
  • Phone: 417-767-2100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2005019247
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: