Provider Demographics
NPI:1538270368
Name:YOUNG, MARK C (DDS INC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:C
Last Name:YOUNG
Suffix:
Gender:M
Credentials:DDS INC
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:C
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS INC
Mailing Address - Street 1:314 SO 12TH AVE
Mailing Address - Street 2:SUITE #3
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3149
Mailing Address - Country:US
Mailing Address - Phone:509-453-4504
Mailing Address - Fax:509-573-4941
Practice Address - Street 1:314 SO 12TH AVE
Practice Address - Street 2:SUITE #3
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3149
Practice Address - Country:US
Practice Address - Phone:509-453-4504
Practice Address - Fax:509-573-4941
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA62441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA207871100000OtherPREMERA BLUE CROSS
WA0595OtherWASHINGTON DENTAL SERVICE
WA5026075Medicare ID - Type Unspecified