Healthcare Provider Details

I. General information

NPI: 1215226469
Provider Name (Legal Business Name): KAELAN DENDY YOUNG BLACK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAELAN DENDY YOUNG

II. Dates (important events)

Enumeration Date: 03/28/2011
Last Update Date: 08/29/2025
Certification Date: 08/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 UNIVERSITY DR STE 300
FAIRFAX VA
22030-2503
US

IV. Provider business mailing address

3801 UNIVERSITY DR STE 200
FAIRFAX VA
22030-2503
US

V. Phone/Fax

Practice location:
  • Phone: 703-383-8130
  • Fax: 703-383-7350
Mailing address:
  • Phone: 703-383-8130
  • Fax: 703-383-7353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberMD223309
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number0101263011
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: