Basic Information
| Provider Information | |||||||||
| NPI: | 1356346282 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 140 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CUBA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147271317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859682000 | ||||||||
| FaxNumber: | 5859683898 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CUBA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147271317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859682000 | ||||||||
| FaxNumber: | 5859683898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 10/24/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 034838 | NY | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 01370869 | 05 | NY | MEDICAID |