Provider Demographics
NPI:1043481609
Name:YOUNG, SALLY (DMD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 NORTHSIDE DR E
Mailing Address - Street 2:SUITE 5, PMB #395
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-4712
Mailing Address - Country:US
Mailing Address - Phone:912-489-1386
Mailing Address - Fax:912-764-8533
Practice Address - Street 1:2 LESTER CT
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-2118
Practice Address - Country:US
Practice Address - Phone:912-489-1386
Practice Address - Fax:912-764-8533
Is Sole Proprietor?:No
Enumeration Date:2008-03-21
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA100991223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00328314BMedicaid