Provider Demographics
NPI:1407307986
Name:YOUNG FAMILY DENTAL INC
Entity Type:Organization
Organization Name:YOUNG FAMILY DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-224-0222
Mailing Address - Street 1:8159 S. 4800 W.
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-8213
Mailing Address - Country:US
Mailing Address - Phone:801-601-8200
Mailing Address - Fax:801-996-3641
Practice Address - Street 1:8159 S. 4800 W.
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-8213
Practice Address - Country:US
Practice Address - Phone:801-601-8200
Practice Address - Fax:801-996-3641
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YOUNG FAMILY DENTAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4766943122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4766943Medicaid