MEDICARE: SCOTT ELLEDGE DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DD3288	NM
2	1223G0001X	General Practice Dentistry	DD3288	NM

General Provider Information

NPI Number	:	1952620338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SCOTT ELLEDGE DMD

Provider Business Mailing Address
First Line	:	1496 S SAINT FRANCIS DR
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-4038
Country	:	US
Telephone Number	:	505-983-4491
Fax Number	:

Provider Business Practice Location Address
First Line	:	1496 S SAINT FRANCIS DR
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-4038
Country	:	US
Telephone Number	:	505-983-4491
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2010
Last Update Date	:	05/24/2010

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Directions to “ SCOTT ELLEDGE DMD” Practice Location

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