Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 2901013995 | MI |
NPI | 1073656195 |
---|---|
Provider Name | Dr. Edward D Young |
First Address | Grand Rapids, MI 49534-8447 |
Second Address | Grand Rapids, MI 49534-8447 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/02/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4563730 | (05) | MI |