Provider Demographics
NPI:1902907272
Name:DE YOUNG, DIRK T (DDS)
Entity Type:Individual
Prefix:DR
First Name:DIRK
Middle Name:T
Last Name:DE YOUNG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-4907
Mailing Address - Country:US
Mailing Address - Phone:360-653-2783
Mailing Address - Fax:360-653-3328
Practice Address - Street 1:1222 2ND ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-4907
Practice Address - Country:US
Practice Address - Phone:360-653-2783
Practice Address - Fax:360-653-3328
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000076521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA57652OtherWDS
WA5034160Medicaid
WADE5381OtherREGENCE BLUE SHIELD