MEDICARE: STANLEY A. YOUNG D.D.S. P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	12007190	IN

General Provider Information

NPI Number	:	1467661041
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STANLEY A. YOUNG D.D.S. P.C.

Provider Business Mailing Address
First Line	:	6038 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-7639
Country	:	US
Telephone Number	:	260-493-3526
Fax Number	:	260-749-8033

Provider Business Practice Location Address
First Line	:	6038 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-7639
Country	:	US
Telephone Number	:	260-493-3526
Fax Number	:	260-749-8033

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. STANLEY A YOUNG
Credential	:	D.D.S.
Telephone Number	:	260-493-3526

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	08/30/2007

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