Provider Demographics
NPI:1124593405
Name:YOUNG, ELLERY GRACE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELLERY
Middle Name:GRACE
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 1:203 N WASHINGTON ST STE 300
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-0254
Mailing Address - Country:US
Mailing Address - Phone:509-444-8888
Mailing Address - Fax:509-444-7806
Practice Address - Street 1:1502 N VERCLER RD
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216
Practice Address - Country:US
Practice Address - Phone:509-444-8200
Practice Address - Fax:509-444-7806
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60877908122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1275052359OtherSTATE