Provider Demographics
NPI:1457005654
Name:YOUNG, BLAKE
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 SOUTHPARK BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-5072
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 SOUTHPARK BLVD STE C
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-5072
Practice Address - Country:US
Practice Address - Phone:336-788-5073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC127431223G0001X
NC390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1275751224OtherLEAL, SPANGLER AND JOHNSON DDS, PA GROUP NPI