Healthcare Provider Details

I. General information

NPI: 1114210531
Provider Name (Legal Business Name): LORETTE M. POLITE-YOUNG DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2011
Last Update Date: 05/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2514 CUTHBERTSON RD SUITE B
WAXHAW NC
28173-6416
US

IV. Provider business mailing address

2514 CUTHBERTSON RD SUITE B
WAXHAW NC
28173-6416
US

V. Phone/Fax

Practice location:
  • Phone: 704-243-5898
  • Fax: 704-843-4516
Mailing address:
  • Phone: 704-243-5898
  • Fax: 704-843-4516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7797
License Number StateNC

VIII. Authorized Official

Name: DR. LORETTE M POLITE-YOUNG
Title or Position: PRESIDENT
Credential: DDS
Phone: 803-548-8377