Provider Demographics
NPI:1962615492
Name:YOUNG AT HEART DENTISTRY
Entity type:Organization
Organization Name:YOUNG AT HEART DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:PURCELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-543-7123
Mailing Address - Street 1:2603 VINEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-3370
Mailing Address - Country:US
Mailing Address - Phone:719-564-6464
Mailing Address - Fax:719-564-1818
Practice Address - Street 1:2603 VINEWOOD LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-3370
Practice Address - Country:US
Practice Address - Phone:719-564-6464
Practice Address - Fax:719-564-1818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO70551223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO91284546Medicaid