Provider Demographics
NPI:1013340702
Name:YOUNG, NICOLE ANN MARIE (RDH)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN MARIE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 NE 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-5420
Mailing Address - Country:US
Mailing Address - Phone:208-642-9376
Mailing Address - Fax:208-642-9598
Practice Address - Street 1:1441 NE 10TH AVE
Practice Address - Street 2:
Practice Address - City:PAYETTE
Practice Address - State:ID
Practice Address - Zip Code:83661-5420
Practice Address - Country:US
Practice Address - Phone:208-642-9376
Practice Address - Fax:208-642-9598
Is Sole Proprietor?:No
Enumeration Date:2013-08-16
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDDH2488124Q00000X
ORH5241124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist