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General NPI Number Information
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NPI Number | 1720704729
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Entity Type | Organization
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Legal Business Name | DE YOUNG DENTAL ASSOCIATES, PLLC
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Dates
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Enumeration Date | 10/12/2022
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Last Update Date | 10/12/2022
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Provider Practice Location Address
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Address Line | 1869 PORTER ST SW
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City | WYOMING
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State | MI
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Zip | 49519-1709
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Country | US
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Telephone | 616-532-7601
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Fax |
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Provider Business Mailing Address
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Address Line | 1869 PORTER ST SW
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City | WYOMING
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State | MI
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Zip | 49519-1709
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. RANDALL SCOTT DE YOUNG
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Credential | DDS
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Telephone | 616-821-3851
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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