Provider Demographics
NPI:1558893768
Name:YOUNG ORTHODONTICS PC
Entity type:Organization
Organization Name:YOUNG ORTHODONTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MSD
Authorized Official - Phone:812-639-8443
Mailing Address - Street 1:5108 BELLEMEADE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-4134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5108 BELLEMEADE AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-4134
Practice Address - Country:US
Practice Address - Phone:812-477-9294
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011014A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty