Provider Demographics
NPI:1982638391
Name:YOUNG, BRENTON L (DDS)
Entity Type:Individual
Prefix:
First Name:BRENTON
Middle Name:L
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:PO BOX 656
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28151-0656
Mailing Address - Country:US
Mailing Address - Phone:704-482-7986
Mailing Address - Fax:704-480-9301
Practice Address - Street 1:139 W ROSS GROVE ROAD
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3406
Practice Address - Country:US
Practice Address - Phone:704-482-7986
Practice Address - Fax:704-480-9301
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC70401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC9009LOtherBLUE CROSS BLUE SHIELD
NC899009LMedicaid
NCT63943Medicare UPIN
NC241351Medicare PIN