Provider Demographics
NPI:1710134085
Name:ROLAND I. YOUNG, DDS, INC.
Entity Type:Organization
Organization Name:ROLAND I. YOUNG, DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:IAN
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:209-522-9963
Mailing Address - Street 1:1316 COFFEE RD STE E14
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-3191
Mailing Address - Country:US
Mailing Address - Phone:209-522-9963
Mailing Address - Fax:209-522-5184
Practice Address - Street 1:1316 COFFEE RD STE E14
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-3191
Practice Address - Country:US
Practice Address - Phone:209-522-9963
Practice Address - Fax:209-522-5184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA295381223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB29538-01Medicaid
CADSO295380Medicare PIN
CAB29538Medicare UPIN