Healthcare Provider Details

I. General information

NPI: 1780887984
Provider Name (Legal Business Name): PERRY BLAKE YOUNG DDS, OMS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W MOANA LN STE 5
RENO NV
89509-4959
US

IV. Provider business mailing address

601 W MOANA LN STE 5
RENO NV
89509-4959
US

V. Phone/Fax

Practice location:
  • Phone: 775-828-2999
  • Fax:
Mailing address:
  • Phone: 775-828-2999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberS2-21
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2319
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberS2-21
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: