Provider Demographics
NPI:1104227883
Name:YOUNG SMILES CHILDREN'S DENTISTRY LLC
Entity type:Organization
Organization Name:YOUNG SMILES CHILDREN'S DENTISTRY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:DALLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-404-9888
Mailing Address - Street 1:114 MINNIE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-3000
Mailing Address - Country:US
Mailing Address - Phone:907-452-4509
Mailing Address - Fax:
Practice Address - Street 1:114 MINNIE ST
Practice Address - Street 2:SUITE A
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-3000
Practice Address - Country:US
Practice Address - Phone:907-452-4509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DALLIN C YOUNG DDS, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-12
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKDEN D15761223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty