Provider Demographics
NPI:1467223651
Name:YOUNG SMILES PEDIATRIC DENTISTRY- SOUTHGATE PLLC
Entity Type:Organization
Organization Name:YOUNG SMILES PEDIATRIC DENTISTRY- SOUTHGATE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:MAYES
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-781-4100
Mailing Address - Street 1:525 ALEXANDRIA PIKE STE 330
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:KY
Mailing Address - Zip Code:41071-3243
Mailing Address - Country:US
Mailing Address - Phone:859-781-4100
Mailing Address - Fax:859-781-0170
Practice Address - Street 1:525 ALEXANDRIA PIKE STE 330
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:KY
Practice Address - Zip Code:41071-3243
Practice Address - Country:US
Practice Address - Phone:859-781-4100
Practice Address - Fax:859-781-0170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty