Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 007392 | GA |
NPI | 1003019050 |
---|---|
Provider Name | Dr. Walter Fuller Young |
First Address | Atlanta, GA 30311-2801 |
Second Address | Atlanta, GA 30311-2801 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/06/2007 |
Last Update Date | 24/10/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00057153A | (05) | GA |