Provider Demographics
NPI:1225468242
Name:YOUNG SMILES PEDIATRIC DENTISTRY & SPA P.A
Entity Type:Organization
Organization Name:YOUNG SMILES PEDIATRIC DENTISTRY & SPA P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KERA
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:813-829-9075
Mailing Address - Street 1:PO BOX 486
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-0486
Mailing Address - Country:US
Mailing Address - Phone:813-829-9075
Mailing Address - Fax:813-236-9007
Practice Address - Street 1:13131 KINGS LAKE DR
Practice Address - Street 2:SUITE # 104
Practice Address - City:GIBSONTON
Practice Address - State:FL
Practice Address - Zip Code:33534-3959
Practice Address - Country:US
Practice Address - Phone:813-829-9075
Practice Address - Fax:813-236-9006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-13
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070219600Medicaid