Provider Demographics
NPI:1972170066
Name:YOUNG, JACOB OVERTON (DDS)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:OVERTON
Last Name:YOUNG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 BRICKWORKS DR APT 1209
Mailing Address - Street 2:
Mailing Address - City:CAYCE
Mailing Address - State:SC
Mailing Address - Zip Code:29033-4432
Mailing Address - Country:US
Mailing Address - Phone:417-429-7777
Mailing Address - Fax:
Practice Address - Street 1:5540 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-9262
Practice Address - Country:US
Practice Address - Phone:803-358-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC99061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice