Provider Demographics
NPI:1841483302
Name:YOUNG, JORDAN D (DMD)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:D
Last Name:YOUNG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-4139
Mailing Address - Country:US
Mailing Address - Phone:360-887-2333
Mailing Address - Fax:
Practice Address - Street 1:109 S 65TH AVE STE 104
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:WA
Practice Address - Zip Code:98642-3708
Practice Address - Country:US
Practice Address - Phone:360-887-2333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-19
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8952122300000X
WADE00011193122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist