Provider Demographics
NPI:1801027917
Name:YOUNG, SHANNON (DMD)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USA DENTAL CLINIC
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96376-5115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:USA DENTAL CLINIC
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96376-5115
Practice Address - Country:US
Practice Address - Phone:01181611-744-4370
Practice Address - Fax:01181611-744-4180
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ78201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice