Provider Demographics
NPI:1104493410
Name:DE YOUNG, RANDALL SCOTT (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:SCOTT
Last Name:DE YOUNG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 144TH AVE
Mailing Address - Street 2:
Mailing Address - City:DORR
Mailing Address - State:MI
Mailing Address - Zip Code:49323-9707
Mailing Address - Country:US
Mailing Address - Phone:616-821-3851
Mailing Address - Fax:
Practice Address - Street 1:1869 PORTER ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-1709
Practice Address - Country:US
Practice Address - Phone:616-532-7601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-06
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRES.004364122300000X
MI2901600996122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist