Provider Demographics
NPI:1740388644
Name:YOUNG, GRANT RICHARD (DDS)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:RICHARD
Last Name:YOUNG
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 1:609 JACKSON
Mailing Address - Street 2:GRANT R YOUNG DDS
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403
Mailing Address - Country:US
Mailing Address - Phone:715-845-6222
Mailing Address - Fax:715-845-6222
Practice Address - Street 1:609 JACKSON
Practice Address - Street 2:GRANT R YOUNG DDS
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403
Practice Address - Country:US
Practice Address - Phone:715-845-6222
Practice Address - Fax:715-845-6222
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI00032011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice