Provider Demographics
NPI:1699303446
Name:YOUNG GREENFIELD DENTAL PRACTICE LLC
Entity type:Organization
Organization Name:YOUNG GREENFIELD DENTAL PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:C
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-902-3185
Mailing Address - Street 1:2850 E FAIRWAY VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-8160
Mailing Address - Country:US
Mailing Address - Phone:317-902-3185
Mailing Address - Fax:765-932-5174
Practice Address - Street 1:1798 MELODY LN
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-1191
Practice Address - Country:US
Practice Address - Phone:317-468-9996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-28
Last Update Date:2020-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1396966073Medicaid