Provider Demographics
NPI:1699863654
Name:YOUNG AND SHORT, A DENTAL CORPORATION
Entity type:Organization
Organization Name:YOUNG AND SHORT, A DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:P
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-861-2661
Mailing Address - Street 1:646 N DIAMOND BAR BLVD
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-1037
Mailing Address - Country:US
Mailing Address - Phone:909-861-2661
Mailing Address - Fax:909-861-6951
Practice Address - Street 1:646 N DIAMOND BAR BLVD
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-1037
Practice Address - Country:US
Practice Address - Phone:909-861-2661
Practice Address - Fax:909-861-6951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31170122300000X
CA326621223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty