Provider Demographics
NPI:1073656195
Name:YOUNG, EDWARD D (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:D
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 1:4310 LEONARD ST NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-8447
Mailing Address - Country:US
Mailing Address - Phone:616-791-0230
Mailing Address - Fax:
Practice Address - Street 1:4310 LEONARD ST NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49534-8447
Practice Address - Country:US
Practice Address - Phone:616-791-0230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010139951223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4563730Medicaid