Basic Information
Provider Information | |||||||||
NPI: | 1720241359 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | YOUNG | ||||||||
FirstName: | MERVIN | ||||||||
MiddleName: | BRIGHAM | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.D.S. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6950 NE CAMPUS WAY | ||||||||
Address2: |   | ||||||||
City: | HILLSBORO | ||||||||
State: | OR | ||||||||
PostalCode: | 971245611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 8950 W EMERALD ST | ||||||||
Address2: | SUITE 108 | ||||||||
City: | BOISE | ||||||||
State: | ID | ||||||||
PostalCode: | 837044854 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2086728682 | ||||||||
FaxNumber: | 2086728684 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2008 | ||||||||
LastUpdateDate: | 05/13/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | D-4166 | ID | Y |   | Dental Providers | Dentist | General Practice |
No ID Information.