=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114210531
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LORETTE M. POLITE-YOUNG DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2011
-----------------------------------------------------
Last Update Date | 05/18/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2514 CUTHBERTSON RD SUITE B
-----------------------------------------------------
City | WAXHAW
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28173-6416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-243-5898
-----------------------------------------------------
Fax | 704-843-4516
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2514 CUTHBERTSON RD SUITE B
-----------------------------------------------------
City | WAXHAW
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28173-6416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-243-5898
-----------------------------------------------------
Fax | 704-843-4516
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LORETTE M POLITE-YOUNG
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 803-548-8377
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 7797
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------