Healthcare Provider Details

I. General information

NPI: 1346306859
Provider Name (Legal Business Name): REGINALD S YOUNG D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 VIRGINIA AVENUE
CLARKSVILLE VA
23927
US

IV. Provider business mailing address

611 VIRGINIA AVENUE
CLARKSVILLE VA
23927
US

V. Phone/Fax

Practice location:
  • Phone: 434-374-2137
  • Fax: 434-374-0940
Mailing address:
  • Phone: 434-374-2137
  • Fax: 434-374-0940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401005327
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: