1578664330 NPI number — JERRY E. YOUNG, D.D.S., P.A.

Table of content: (NPI 1578664330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578664330 NPI number — JERRY E. YOUNG, D.D.S., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JERRY E. YOUNG, D.D.S., P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578664330
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
208 WEST 4TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLTON
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66436
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-364-4636
Provider Business Mailing Address Fax Number:
785-364-4815

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 WEST 4TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLTON
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-364-4636
Provider Business Practice Location Address Fax Number:
785-364-4815
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
785-364-4636

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  4625 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 17207 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 627506 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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