Basic Information
| Provider Information | |||||||||
| NPI: | 1003292608 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNGBERG | ||||||||
| FirstName: | JEFFREY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 770 MASON ST | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | VACAVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956884646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074471010 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 770 MASON ST | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | VACAVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956884646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074471010 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2015 | ||||||||
| LastUpdateDate: | 03/16/2017 | ||||||||
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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 | 64725 | CA | Y | Dental Providers | Dentist |
No ID Information.