Provider Demographics
NPI:1497858872
Name:JONES, ETHAN YOUNG (DDS)
Entity Type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:YOUNG
Last Name:JONES
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 1:1001 E STUART DRIVE
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333
Mailing Address - Country:US
Mailing Address - Phone:276-236-0562
Mailing Address - Fax:276-236-0858
Practice Address - Street 1:1001 E STUART DRIVE
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333
Practice Address - Country:US
Practice Address - Phone:276-236-0562
Practice Address - Fax:276-236-0858
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA79091223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC899008LMedicaid
743169OtherUNITED CONCORDIA