Provider Demographics
NPI:1548306905
Name:YOUNG, DELY A
Entity type:Individual
Prefix:
First Name:DELY
Middle Name:A
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DELY
Other - Middle Name:YOUNG
Other - Last Name:CU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:126 SECOND AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401
Mailing Address - Country:US
Mailing Address - Phone:650-343-3836
Mailing Address - Fax:650-343-0528
Practice Address - Street 1:126 SECOND AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401
Practice Address - Country:US
Practice Address - Phone:650-343-3836
Practice Address - Fax:650-343-0528
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34269122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
B3426901OtherMEDICAL