Provider Demographics
NPI:1306972658
Name:YOUNG, GLENN RICHARD (DDS)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:RICHARD
Last Name: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 1:974 73RD ST
Mailing Address - Street 2:STE.#3
Mailing Address - City:WINDSOR HEIGHTS
Mailing Address - State:IA
Mailing Address - Zip Code:50312-1024
Mailing Address - Country:US
Mailing Address - Phone:515-224-1771
Mailing Address - Fax:515-224-1771
Practice Address - Street 1:974 73RD ST
Practice Address - Street 2:STE.#3
Practice Address - City:WINDSOR HEIGHTS
Practice Address - State:IA
Practice Address - Zip Code:50312-1024
Practice Address - Country:US
Practice Address - Phone:515-224-1771
Practice Address - Fax:515-224-1771
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA78091223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0134098Medicaid