Provider Demographics
NPI:1134287626
Name:YOUNG, BURTON RAY (DMD)
Entity Type:Individual
Prefix:DR
First Name:BURTON
Middle Name:RAY
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 1:111 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-2358
Mailing Address - Country:US
Mailing Address - Phone:270-753-1206
Mailing Address - Fax:270-753-1216
Practice Address - Street 1:111 S 13TH ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-2358
Practice Address - Country:US
Practice Address - Phone:270-753-1206
Practice Address - Fax:270-753-1216
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY45241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYY486OtherFEP PROVIDER #
KY144483OtherANTHEM PROVIDER #
KY60045242Medicaid