Provider Demographics
NPI:1285639831
Name:YOUNG, M. WALTER (DDS)
Entity Type:Individual
Prefix:DR
First Name:M.
Middle Name:WALTER
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 1:11952 MONTFORT CIR
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5761
Mailing Address - Country:US
Mailing Address - Phone:804-360-3102
Mailing Address - Fax:
Practice Address - Street 1:7820 SHRADER RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23294-4222
Practice Address - Country:US
Practice Address - Phone:804-262-1060
Practice Address - Fax:804-264-0445
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-19
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104-0050541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice