Provider Demographics
NPI:1083870232
Name:YOUNG, DANIEL (DMD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 NATIONAL DR STE 102
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-6709
Mailing Address - Country:US
Mailing Address - Phone:608-783-3636
Mailing Address - Fax:
Practice Address - Street 1:2700 NATIONAL DR STE 102
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-6709
Practice Address - Country:US
Practice Address - Phone:608-783-3636
Practice Address - Fax:608-783-3639
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-06
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001778-151223E0200X
CODEN.000097311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO51557703Medicaid