MEDICARE: DR. KELLY ELIZABETH YOUNG D.D.S.

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	1223G0001X	General Practice Dentistry	12011027A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12011027A	OTHER	IN	LICENSE NUMBER

General Provider Information

NPI Number	:	1851598833
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY ELIZABETH YOUNG D.D.S.

Provider Business Mailing Address
First Line	:	1219 RED DUNES RUN
Second Line	:
City	:	AVON
State	:	IN
Zip	:	46123-9536
Country	:	US
Telephone Number	:	812-482-4321
Fax Number	:	812-634-6809

Provider Business Practice Location Address
First Line	:	2005 SAINT CHARLES ST STE 5
Second Line	:
City	:	JASPER
State	:	IN
Zip	:	47546-9146
Country	:	US
Telephone Number	:	812-482-4321
Fax Number	:	812-634-6809

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2007
Last Update Date	:	07/08/2007

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Directions to “ DR. KELLY ELIZABETH YOUNG D.D.S.” Practice Location

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