Provider Demographics
NPI:1720704729
Name:DE YOUNG DENTAL ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:DE YOUNG DENTAL ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:DE YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-821-3851
Mailing Address - Street 1:1869 PORTER ST SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-1709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1869 PORTER ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-1709
Practice Address - Country:US
Practice Address - Phone:616-532-7601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental