Provider Demographics
NPI:1962112516
Name:YOUNG, KIM NICOLE (RDH)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:NICOLE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:NICOLE
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDH
Mailing Address - Street 1:1409 W 43RD ST
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37409-1360
Mailing Address - Country:US
Mailing Address - Phone:423-602-3686
Mailing Address - Fax:
Practice Address - Street 1:4501 AMNICOLA HWY
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37406-1018
Practice Address - Country:US
Practice Address - Phone:423-697-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8088124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist