Provider Demographics
NPI:1528137171
Name:YOUNG, CHARLES EDMUND JR (DDS)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDMUND
Last Name:YOUNG
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:E
Other - Last Name:YOUNG
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:624 W POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-2540
Mailing Address - Country:US
Mailing Address - Phone:901-853-2520
Mailing Address - Fax:901-854-9273
Practice Address - Street 1:624 W POPLAR AVE
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-2540
Practice Address - Country:US
Practice Address - Phone:901-853-2520
Practice Address - Fax:901-854-9273
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000023041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice