Provider Demographics
NPI:1366568370
Name:YOUNG, PETER P JR (DMD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:P
Last Name:YOUNG
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 W COLORADO ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-3097
Mailing Address - Country:US
Mailing Address - Phone:818-956-2237
Mailing Address - Fax:
Practice Address - Street 1:412 W COLORADO ST
Practice Address - Street 2:SUITE C
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-3097
Practice Address - Country:US
Practice Address - Phone:818-956-2237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA219681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice