Provider Demographics
NPI:1043830003
Name:YOUNG, SHANNON (DDS)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40255 GRAND RIVER AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-2149
Mailing Address - Country:US
Mailing Address - Phone:248-476-7711
Mailing Address - Fax:
Practice Address - Street 1:40255 GRAND RIVER AVE STE 100
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2149
Practice Address - Country:US
Practice Address - Phone:248-476-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901600501APP201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice